Depression Chapter 5

Transcription

O N TA R I O W O M E N ’ S
H E A LT H E Q U I T Y R E P O R T
Depression
Chapter 5
AUTHORS
INSIDE
Elizabeth Lin, PhD
Natalia Diaz-Granados, MSc
Donna E. Stewart, MD, FRCPC
Anne E. Rhodes, PhD
Naira Yeritsyan, MD, MPH
Ashley Johns, MSc
Minh Duong-Hua, MSc
Arlene S. Bierman, MD, MS, FRCPC
• Background Measures
• Primary and Specialty
Outpatient Care
• Acute and Specialty
Inpatient Care
Improving Health and Promoting Health Equity in Ontario
ONTARIO WOME N’ S HEALTH EQ UI TY REPO RT | Chapter 5
September 2009 • Volume 1 Ontario Women’s Health Equity Report
Acknowledgements
The POWER Study is funded by Echo: Improving Women’s Health in Ontario, an agency of the Ministry of Health
and Long-Term Care. This report does not necessarily reflect the views of Echo or the Ministry.
The POWER Study is a partnership between the Keenan Research Centre in the Li Ka Shing Knowledge Institute
of St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences (ICES) in Toronto.
We would like to thank all the people who helped with this chapter. For details, please see the Preliminary section of Volume 1
at www.powerstudy.ca.
Publication Information
© 2009 St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by
any means, electronic, mechanical, photocopying, recording or otherwise, without the proper written permission of the publisher.
Canadian cataloguing in publication data
Project for an Ontario Women’s Health Evidence-Based Report: Volume 1
Includes bibliographical references
ISBN: 978-0-9733871-1-7
How to cite this publication
The production of Project for an Ontario Women’s Health Evidence-Based Report: Volume 1 was a collaborative venture.
Accordingly, to give credit to individual authors, please cite individual chapters and titles, in addition to the editors and book title.
For this chapter:
Lin E, Diaz-Granados N, Stewart D, Rhodes A, Yeritsyan N, Johns A, Duong-Hua M, Bierman AS. Depression. In: Bierman AS,
editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 2009.
For this volume:
Bierman AS, editor. Project for an Ontario Women’s Health Evidence-Based Report: Volume 1: Toronto; 2009.
The POWER Study
Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital
30 Bond St. (193 Yonge St., 6th floor)
Toronto, ON, M5B 1W8
Tel: (416) 864-6060, Ext 3946
Fax: (416) 864-6057
[email protected]
www.powerstudy.ca
Cover photo © www.istockphoto.com
Project for an Ontario Women’s Health Evidence-Based Report (POWER) Study
Depression
TABLE OF CONTENTS
Executive Summary.................................................................................... 2
Introduction............................................................................................... 10
List of Exhibits........................................................................................... 15
A Guide to Reading Maps........................................................................ 18
Background Measures.............................................................................. 21
Primary and Specialty Outpatient Care . ................................................ 40
Acute and Specialty Inpatient Care ........................................................ 52
Chapter Summary of Findings................................................................. 70
Discussion.................................................................................................. 73
Improving Depression Care: Different Approaches.................................... 80
Appendix 5.1 Indicators and Their Links
to Provincial Strategic Objectives............................................................ 84
Appendix 5.2 Indicators and Their Sources . .......................................... 87
Appendix 5.3 How the Research was Done............................................ 90
References............................................................................................... 100
1
Executive Summary
ISSUE
Depression, a common chronic condition, is a tremendous
emotional and financial burden for people who suffer from
it, their families and society. It is the leading cause of diseaserelated disability among women, according to the World
Health Organization.1
Depression has a vast economic impact, and is
population-based Ontario Mental Health Supplement
responsible for lost productivity, increased disability
(1990) found higher disability among women aged
claims and greater use of health care services. In this
15-19 compared to men in that age group: women
chapter we examine the patterns of depression care in
reported 3.4 disability days due to mental health
the province and how they differ by gender, income,
compared to 1.1 days reported by men.20 In addition,
age and where one lives.
women often report different depressive symptoms
than men do, such as having more anxiety, appetite
There are effective treatments for depression that
disturbances and sleep changes.21 Although there
can improve quality of life and health outcomes
is no gender difference in the risk of recurrence of
among those with the disease. Many people with
depression,15 women have longer recurrent episodes.
depression go untreated2-5 and some who are
On the other hand, men are more likely to suffer from
treated may receive suboptimal care.6, 7 Gender and
socioeconomic position are associated both with the
risk of developing depression and the type of depression
alcohol and substance dependence22 and have higher
rates of completed suicide.23
care received.8-11 Quality improvement interventions
Some women are at increased risk of depression
have been shown to improve quality and outcomes of
and special efforts need to be made to provide care
depression care.
12-14
and support for them. There is evidence that some
immigrant and ethnic minority women may be at
Women in developed countries are twice as likely to
increased risk of depression, therefore cultural sensitivi-
suffer from depression as men10, 15-17 and research
ties must be considered in delivering depression services.
shows numerous differences in how the two sexes
experience the disease. Women tend to have onset of
depression at a younger age and experience greater
province may be large since approximately 27 percent
of Ontario’s population is foreign-born and 40 percent
severity of illness than men. They also report more
functional impairment, poorer social adjustment and
worse quality of life.18, 19 A report using data from the
2
The need for culturally sensitive depression services in the
are first- or second-generation immigrants.24, 25 Rural
women and men may be less likely to receive treatment
Depression | Executive Summary
due to limited availability of services.4 Finally, women in
8
lower-income households or who live in low-income
neighbourhoods26 were also significantly more likely to
have depression than those in higher-income brackets
or neighbourhoods. Targeting depression services to
those with the highest 'need' is essential to reducing
the burden of this treatable disorder and achieving the
best possible outcomes.
study
This chapter uses a set of evidence-based indicators to
assess gender, income, age and regional differences in
depression care among Ontarians living with depression.
Indicators were chosen by a Technical Expert Panel (TEP)
using a modified Delphi process (see The POWER Study
Framework, chapter 2). We used the continuum of
care (Figure 1) to guide the identification of important
gender gaps in depression care and a review of relevant
measures from the published and grey literature (for
ABOUT THIS CHAPTER
details see Appendix 5.3). These indicators are intended
The chapter has three sections:
understand where there are sex and sociodemographic
A.Background Measures
This section provides a snapshot of the need
for, use and supply of mental health care
services in Ontario.
B.Primary and Specialty Outpatient
Care Indicators
to help administrators, policy makers and providers
disparities in depression care, create new policies and
programs for dealing with gender gaps and reduce the
barriers that keep both women and men from getting
the depression care they need.
We used multiple data sources in this report including
the Canadian Community Health Survey (CCHS), Cycle
1.1 (2000/01); Daily Census Summary Report Mental
This section presents and discusses indicators
Health Beds online, Ministry of Health and Long-Term
of depression care in outpatient settings.
Care (MOHLTC) Health Data Branch; Canadian Institute
Because of data limitations, only care provided
for Health Information Discharge Abstract Database
by Ontario physicians paid by fee-for-service
(CIHI-DAD); Ontario Health Insurance Plan (OHIP)
could be measured.
physician claims data; National Ambulatory Care
Reporting System (NACRS); Ontario Drug Benefit (ODB)
C.Acute and Specialty Inpatient
Care Indicators
database; Institute for Clinical Evaluative Sciences (ICES)
Physician Database (IPDB); ICES Mother-Baby Linked
This section covers indicators of depression
database (MOMBABY) and Statistics Canada 2001
care provided in inpatient settings and on
Census. A complete list of the indicators reported in
transition back to the community.
this chapter and their data sources can be found in
Appendix 5.2.
All indicators are reported at the provincial level and
at the Local Health Integration Network (LHIN) level
when sample size allowed. All analyses were stratified
by sex (where applicable), and then by age, income or
rural/urban residency. Age-adjustment was done using
indirect standardization. Appendix 5.3 provides
a description of the research methods.
3
Key Findings
In this chapter we present background measures of the
There were also differences in which service sectors
need, use and supply of depression care in Ontario, as
were used. Women and men from the lowest-income
well as indicators of inpatient and outpatient depression
areas were almost twice as likely to be hospitalized for
care. Figure 5 provides a summary of where sex,
depression but incurred slightly lower average costs for
income, age and regional differences were found.
OHIP core mental health services compared to Ontarians
living in the highest-income areas (Exhibit 5A.9).
Overall, we found many instances where
depression care was suboptimal for everyone. Less
than half of women and men with probable depression
had a physician visit for this condition. Many older
adults who started on antidepressant therapy did not
receive the recommended number of follow up visits
for management (i.e., three or more visits within 12
weeks of starting medication). One in three women
and men who were hospitalized for depression did not
have a follow up physician visit for depression within 30
days of hospital discharge and nearly one in five were
seen in the emergency department in this time frame,
indicating suboptimal care coordination during care
Rural residents were more likely to be hospitalized for
depression while urban dwellers accounted for
proportionately greater OHIP costs for mental health
care (Exhibit 5A.10).
A comparison of need, use and supply across
LHINs suggested that the geographic patterns of
use reflected the geographic distribution of supply
more than need.
We report results for several indicators of depression
care. For some indicators, we found no significant
sex differences. Women and men with probable
depression had similar rates of having a physician visit
for depression within a one-year period (Exhibit 5B.1).
transitions.
We found differences in the prevalence of
depression—one of the important markers of need
for depression care—across sex, income, age and
geography. We also found differences in the use
of services for both depression and mental health
Men and women aged 66 and older, starting on a new
course of antidepressants, were equally likely to have
had the recommended number of follow up visits
(Exhibit 5B.4). And women and men who were
hospitalized for depression were equally likely to be
in general. In some cases, the prevalence patterns
readmitted for depression (Exhibit 5C.12) or to have
were similar to the service use patterns. For example,
visited the emergency department (Exhibit 5C.8) in the
women had higher rates of both depression and use
month after they were discharged.
of Ontario Health Insurance Plan (OHIP) core mental
health services (Exhibit 5A.8). In other cases, however,
they were not. Low-income women were more likely
to report probable depression (Exhibit 5A.1) but had
similar rates of use of OHIP core mental health services
as higher-income women (Exhibit 5A.5).
4
There were some gender differences. Among people
who were hospitalized for depression, women were
more likely than men to have seen a physician for
depression post-discharge (Exhibit 5C.5). For those who
were seen within 30 days of discharge, there was no
difference in how long women and men took to get a
to do so more quickly) than those from lower-income
follow up visit within the first 30 days after discharge.
neighbourhoods (Exhibit 5C.1). And, men living in the
Beyond 30 days, men took somewhat longer to have a
lowest-income neighbourhoods were more likely than
physician visit.
men from the highest-income neighbourhoods to visit
A few indicators showed differences in depression
care associated with age. Ontarians with probable
an emergency department in the month after a hospital
stay for depression (Exhibit 5C.8).
depression aged 45-64 were the most likely to visit
Some rural/urban differences were found. Urban
a physician for depression (Exhibit 5B.2), although
dwellers were more likely to have a post-discharge
they were not the group with the highest prevalence.
physician visit for depression than those from rural areas
Among older Ontarians starting antidepressants, age
(Exhibit 5C.2). Also, men from rural areas were more
was associated with a decreasing likelihood of adequate
likely to visit an emergency department after discharge
physician follow up (i.e., three or more visits within
than those from urban areas.
the 12 weeks after starting medication) for depression
Variations across Local Health Integration
Networks (LHINs) were found for a number of
indicators, and these represented the largest
(Exhibit 5B.5) but an increasing likelihood of physician
visits for any reason.
Disparities by income were found for several
indicators. Among women with probable depression,
those with lower annual household incomes were more
likely to see a physician for depression than those with
higher annual household incomes (Exhibit 5B.1). Among
women aged 66 and older, those from lower-income
neighbourhoods who started antidepressants were less
likely to have had the recommended number of follow
up physician visits than women from higher-income
neighbourhoods (Exhibit 5B.4). Among Ontarians who
had been hospitalized for depression, people who lived
in higher-income neighbourhoods were more likely to
disparities reported in this chapter. Differences
between the highest and lowest LHINs ranged from
roughly one-and-a-half times as large (physician visits
for depression within 30 days of hospital discharge)
(Exhibit 5C.3) to twice as large (percentage of adults
aged 66 and older, starting a new course of antidepressants who had three or more physician visits for
depression within 12 weeks of starting medication
(Exhibit 5B.6); 30-day post-discharge rate of emergency
department visits (Exhibit 5C.10)) to as high as
four times as much (30-day readmission rate for
depression (Exhibit 5C.13)).
have a post-discharge physician visit for depression (and
5
Key Messages
Our findings support the need to re-evaluate care for
• Explore developing care models for specific underserved
depression in Ontario along several fronts and at several
groups (including men, younger people, the elderly,
levels. The indicators chosen for this chapter arise from
people with low incomes and people who live in rural
evidence-based recommendations or guidelines for
areas) and evaluate their impact, especially when
appropriate depression care and suggest specific and
combined with targeted outreach;
immediate aspects of clinical practice that need further
examination and improvement. The distribution and
organization of existing resources—important elements
in supporting the continuity of care envisioned across
• Implement models to better coordinate care across care
transitions between sectors, particularly from hospital
to home;
• Coordinate depression care with other types of health
the decades of mental health reform in Ontario and
an obvious focus for the newly organized LHINs—will
care, particularly chronic disease management, so that
also play important roles in both improving access and
patients with more than one health problem do not
delivering more appropriate and effective courses of
receive fragmented care;
care in the immediate and medium term. In particular,
• Evaluate the effectiveness of care through routine gender
a wider adoption of collaborative care models for
and equity analyses of indicators of depression care and
depression deserves serious consideration.
its outcomes;
• Improve data capacity to better measure access,
The following actions could help to improve
access to, and the quality of, depression care
quality and outcomes of depression care across the
in Ontario:
care continuum.
• Develop and support collaborative care models in primary
care and across depression care sectors;
6
Key Findings by Section
SECTION A | Background Measures
• Women and men from the lowest-income areas were
almost twice as likely to be hospitalized for depression
Need
• Women were twice as likely to have probable depression as men in Ontario (Exhibit 5A.3). This
finding is consistent with the evidence from the
literature from Canada and from other countries such
10, 15-17
as the US and UK.
• There were regional and income differences in the
prevalence of probable depression. Individuals living
in the lowest-income neighbourhoods were more likely
but incurred slightly lower average costs for OHIP
mental health services than those from higher-income
areas (Exhibit 5A.9).
• Rural and urban residents used services differently.
Rural residents were more likely to be hospitalized
for depression while urban dwellers accounted for a
greater proportion of OHIP costs per capita for mental
health care (Exhibit 5A.10).
to have probable depression than those living in the
Supply
highest-income neighbourhoods (Exhibit 5A.1).
• Resources such as physician supply and psychiatric
• There was no difference in the prevalence of
hospital beds varied markedly across Local Health probable depression based on whether people lived in
Integration Networks (LHINs). The differences between
rural or urban areas (Exhibit 5A.10).
the highest and lowest rates per 100,000 population
• Women with probable depression were somewhat
more likely to report comorbid chronic medical conditions
than men. However, there were few differences by sex
in self-rated health or self-reported functioning among
those with probable depression (Exhibit 5A.3).
Use
• There were distinct sex differences in use of services
among LHINs ranged from twice as many general
practitioners (GPs) or family physicians (FPs) to three
times as many hospital beds and 12 times as many
psychiatrists (Exhibits 5A.11, 5A.12).
Patterns of need, use and supply
• Patterns of service use appeared to reflect supply
more than need (Exhibit 5A.13).
for depression. Women were between one and a half
SECTION B | Primary and Specialty
to two times more likely than men to use OHIP core
mental health services—a pattern consistent with their
higher rates of depression (Exhibit 5A.8).
• Although women from lower-income areas were
more likely to have probable depression than those
from higher-income areas, they had similar rates of
use of OHIP core mental health services (Exhibit 5A.5).
However, women from higher-income neighbourhoods
incurred greater OHIP core mental health costs per
capita than women from lower-income neighbourhoods
(Exhibit 5A.6).
Outpatient Care
Care for Ontarians with probable depression
• Sixty percent of Ontarians with probable depression did
not have a physician visit for depression care within the
year after they were interviewed.
• Among those with probable depression, women
and men had similar visit rates of physician visits for
depression—41 percent of women and 37 percent of
men had at least one physician visit for depression
within a year of their survey interview.
7
• Women with probable depression who had lower
• Women were somewhat more likely than men to have
annual household incomes were more likely to see a
seen a physician for depression within 30 days after physician for depression than those with higher annual
discharge from hospital (65 percent of women versus
household incomes (Exhibit 5B.1).
60 percent of men). This pattern held true across
neighbourhood income levels (Exhibit 5C.1), rural/
• Ontarians aged 45-64 with probable depression
were the most likely to visit a physician for depression
(Exhibit 5B.2), although they were not the age group
with the highest disease prevalence.
urban residency (Exhibit 5C.2), and almost all
LHINs (Exhibit 5C.4).
• One year post-discharge, 10 percent of women and 14
Care for older Ontarians starting a new course of
percent of men had not seen a physician for depression.
• There was no difference in how long women and men
antidepressant medication
• Older Ontarians who started antidepressant medication
took to get a follow up visit during the first 30 days after
had low rates of adequate physician follow up for
discharge. Beyond 30 days men took somewhat longer
depression (i.e., three or more visits within 12 weeks of
to have a physician visit (Exhibit 5C.6).
starting medication); 9.5 percent for women and 9.9
• People who lived in higher-income neighbourhoods
percent for men, although roughly 85 percent had at
least three physician visits for any reason in the important
first 12 weeks after starting antidepressants.
and those who lived in urban areas were more likely to
have a post-discharge physician visit for depression
than those from lower-income neighbourhoods or
rural areas. The largest differences, however, were
• Among these older Ontarians, increased age was
associated with a decreasing likelihood of having had
across LHINs, where the rates ranged from 50 percent
three physician visits for depression after starting anti-
to 72 percent (Exhibit 5C.3).
depressant medication (Exhibit 5B.5) but an increasing
likelihood of physician visits for any reason.
Emergency department visits for depression (not
resulting in readmission) after a discharge from a
• Older women from lower-income neighbourhoods
hospital stay for depression
were less likely to have had the recommended number • Women and men were equally likely to have had an
of follow up physician visits for depression after
emergency department visit within 30 days (17 percent
starting their new antidepressants than women from
and 18 percent, respectively) of discharge after a hospital
higher-income neighbourhoods (Exhibit 5B.4).
stay for depression.
Care for postpartum women
• Men living in the lowest-income neighbourhoods were
• Twenty percent of Ontario women who gave birth
more likely to visit an emergency department within 30
had a physician visit for depression within one year
days of discharge after a hospital stay for depression than
following delivery (Exhibit 5B.7).
men from higher-income neighbourhoods (Exhibit 5C.8).
SECTION C | Acute and Specialty Inpatient Care
Physician visits for depression after a discharge
• Men from rural areas were more likely to have had an
emergency department visit within 30 days of discharge
after a hospital stay for depression than those from
from a hospital stay for depression
• One in three Ontarians did not have a physician visit for
urban areas.
depression within 30 days of discharge after a hospital
8
• Sex disparities occurred within age groups; the youngest
women had a higher rate of emergency department
visits in the 30 days post-discharge after a hospital stay
for depression than men that age, but men aged 45-64
had higher rates of use than women (Exhibit 5C.9).
• The largest difference in the percentage of women
and men who had an emergency department visit
in the 30 days post-discharge after a hospital stay
for depression was across LHINs. The highest rate
(21 percent) was almost double the lowest rate
(11 percent) (Exhibit 5C.10).
Readmission to hospital for depression
• Women and men were equally likely to be readmitted
to hospital for depression in the 30 days after a
previous hospital stay (7.6 percent for each).
There were few differences in 30-day readmission rates
across age groups, neighbourhood income levels
(Exhibit 5C.12) and rural/urban residency.
• There were differences across LHINs, however, where
30-day readmission rates ranged from 2.9 percent to
11.9 percent (Exhibit 5C.13).
© www.istockphoto.com
9
Introduction
Depression, a common chronic condition, is a tremendous
emotional and financial burden for people who suffer
from it, their families and society. It is the leading cause of
disease-related disability among women, according to the
World Health Organization.1
Depression has a vast economic impact, and is
functional impairment, poorer social adjustment and
responsible for lost productivity, increased disability
worse quality of life.18, 19 A report using data from the
claims and greater use of health care services.
population-based Ontario Mental Health Supplement
(1990) found higher disability among women aged
There are effective treatments for depression that
15-19 compared to men in that age group: women
can improve quality of life and health outcomes
reported 3.4 disability days due to mental health
for those with the disease. Many people with
compared to 1.1 days reported by men.20 In addition,
depression go untreated2-5 and some who are
women often report different depressive symptoms
treated receive suboptimal care.6, 7 Gender and
than men, such as having more anxiety, appetite
socioeconomic position are associated both with
disturbances and sleep changes.21 Although there
the risk of developing depression and the type of
is no gender difference in the risk of recurrence of
depression care received.8-11 Quality improvement
interventions have been shown to improve quality and
depression,15 women have longer recurrent episodes.
outcomes of depression care.12-14
On the other hand, men are more likely to suffer from
In Ontario, in a 12-month period, 4.8 percent of
rates of completed suicide.23
alcohol and substance dependence22 and have higher
the overall population will suffer from depression.
Ideally the supply and use of health care services for
However, the problem is not evenly distributed: 6.1
percent of women and 3.5 percent of men report being
depressed.8 Ontario’s rates of depression are similar to
the rest of Canada.27, 28 In this chapter we examine the
patterns of depression care in the province and how
they differ by gender, income, age and where one lives.
and women who were single or divorced, those with a
higher education and those born in Canada were most
likely to report using health services for their mental
found that more women reported unmet needs for
suffer from depression as men,10, 15-17 and research
depression care (5.6 percent) than men (3.4 percent).30
shows numerous differences in how the two sexes
experience the disease. Women tend to have onset of
10
after adjusting for variation in need, that women, men
the Canadian Community Health Survey, Cycle 1.2
Women in developed countries are twice as likely to
severity of illness than men. They also report more
prevalence and severity of illness.29 One study found,
health problems.11 Another study that used data from
Gender Differences in Depression
depression at a younger age and experience greater
depression should reflect need and be related to the
They also found that women were two-to-three times
more likely than men to experience barriers to accessibility and acceptability of seeking mental health
Depression | Introduction
care. Women’s access to care was limited due to cost,
transportation, competing responsibilities and language
limitations. Attitudes of providers and the health system
toward mental illness also affected the acceptability
of services.
Some women are at increased risk of depression
and special efforts need to be made to provide care
and support for them. There is evidence that some
immigrant and ethnic minority women may be at
increased risk of depression, therefore cultural sensitivities must be considered in delivering depression
services. The need for culturally sensitive depression
services in the province may be large since approximately 27 percent of Ontario’s population is foreignborn and 40 percent are first- or second-generation
immigrants.24, 25 Rural women and men may be less
likely to receive treatment due to limited availability of
services.4 Finally, women in lower-income households8
or those who live in low-income neighbourhoods26
were also significantly more likely to have depression
than those in higher-income brackets or neighbourhoods. Targeting depression services to those with the
highest 'need' is essential to reducing the burden of
this treatable disorder and achieving the best possible
outcomes.
quality improvement programs to be equally effective
in improving treatment outcomes and quality of life
for women and men,35 but sex disparities remained
for other outcomes such as unmet need for treatment,
burden of depression and quality of life years lost.35, 36
Quality Improvement and Depression Care
Quality improvement programs for depression care
have shown that mental health services can be
improved for depression, but it is not clear whether
These studies also reported that the type of quality
improvement intervention—whether it facilitated
medication management, psychotherapy or both—may
benefit women and men differently.
they benefit men and women equally.13, 31-33 Studies
To reduce the gender inequity in the use of mental
of quality improvement programs for other treatments,
health services, we need to examine the quality of
34
including haemodialysis,
show that sex disparities
mental health care. Ontarians get formal mental
can be reduced for some medical outcomes by
health care through family physicians, psychiatrists,
monitoring patient outcomes, and providing feedback
general hospitals, specialty and tertiary care hospitals,
on performance to health care providers. However, few
community mental health programs and mental
studies have examined whether quality improvement
health provider private practices.37 Although care
programs for depression care affect the sexes
for depression is also provided by other profession-
differently, and those that have, have focused mainly
als such as psychologists, social workers and nurses,
on outpatient primary care services. One study found
as well as by self-help and peer-support programs, we
11
did not include these in the chapter because there are
discussion paper for the province’s ten-year strategy for
no system-wide, linkable data on these services. The
mental health and addictions (Every Door is the Right
quality of mental health services should be monitored
Door: Towards a ten-year mental health and addictions
using structural, process and outcome indicators.38-41
strategy).56 In addition, Echo: Improving Women’s
There is specific national and international attention
Health in Ontario, an agency of the Ontario MOHLTC,
on improving the access to and use of depression
has sponsored consultations across the province on
care resources.42-45 Prior reports, however, have not
improving the health and health care of people with
looked at indicators that assess the broad spectrum of
depression. All of these initiatives share a common goal
'behavioural' health care—that is, the care delivered
of ensuring equitable access to quality mental health
by community mental health workers such as social
care. The indicators in this chapter were selected based
workers, therapists and psychologists46 and none have
on that same goal with the intent that they will support
assessed whether gender inequities exist in the process
the move from policy to implementation.
of the delivery of depression services.
We believe it is vital to consider the impact of gender
because of the significant differences in men's and
women’s needs for depression care and the differences
in how they seek health care. The impact of gender
inequity on performance of indicators for depression
care should be considered along with other factors that
influence need and use of care for depression including
age, income and other socioeconomic factors.47, 48
Gender differences in treatments, other process-related
factors and outcomes should be considered by policy
makers and program planners in developing services
for those with the highest needs and removing barriers
that make gender and sociodemographic inequity
This chapter looks at gender equity in health services for
Ontarians living with depression. Indicators were chosen
by a Technical Expert Panel (TEP) using a modified
Delphi process and an explicit set of indicator selection
criteria (see The POWER Study Framework, chapter 2).
We used the continuum of care shown below (Figure
1) to guide the identification of important gender gaps
in depression care and a review of relevant measures
from the published and grey literature. These measures
were then narrowed down, first by the TEP and then
by determining what was feasible to measure using
available Ontario data (for details see Appendix 5.3).
These indicators are intended to help administrators,
worse.49-53
policy makers and providers understand where there are
Since 1988, when the pivotal Graham report was
released, Ontario has made efforts to develop coherent,
long-range policies and planning for the mental health
system.54 Current efforts include the MOHLTC Mental
Health System Report Card55 and the recently released
12
Delivering Depression Care in Ontario
sex disparities in depression care, create new policies
and programs for dealing with the worst gender gaps
and reduce the barriers that keep both women and
men from getting the depression care they need.
Depression | Introduction
Figure 1: Continuum of Depression Care
CONTINUUM OF DEPRESSION CARE
Prevention/
health
promotion
Community
services/
supports
Primary
care
Specialty
outpatient
care
Acute
hospital
care
Specialty
hospital
care
There is no single cause for depression, which is part
tional, to stabilize them to the point where they can
of the challenge in providing care for it. Clinicians
benefit from community and outpatient services and
and researchers believe many factors play a role in
then effect a smooth discharge.
determining who develops depression and how the
course of their illness runs. These diverse factors include
genetics, childhood experiences, lifestyle and social
circumstances; several may occur together in people
who are clinically depressed. There is no single course
for depression. Some people have only one depressive
episode in their life while others experience recurring
episodes of varying severity.
Ideally, depression should be treated with a range
of integrated and coordinated services, along the
continuum of care (Figure 1). Prevention and health
promotion provide information and initiatives
to reduce the risk of developing or relapsing into
depression. Community services and supports help
people whose condition is relatively stable to cope with
Data limitations prevented us from measuring
prevention and promotion and community services
and supports (see ‘What we can’t measure’ in the
Discussion). The results for the remaining indicators are
organized into three sections:
• Background Measures. The indicator selection
process identified a number of measures that were not
specifically related to individual treatment of depression.
They were, however, important because they described
the Ontario context and therefore help in interpreting
the indicators. This section provides a snapshot of the
need, use and supply of health care services for mental
health in Ontario.
• Primary and Specialty Outpatient Care. Section
everyday living and to improve their quality of life, by
5B presents indicators of depression care in outpatient
addressing factors such as housing, vocational training,
settings. Because of data limitations, only care provided
peer support and social activities and by helping to
by Ontario physicians paid on a fee-for-service basis
coordinate services. Primary care and specialty
could be measured.
outpatient care providers focus on the diagnosis
and clinical treatment of depression, while acute and
specialty hospital inpatient services provide more
intensive care in a structured setting, focusing on
people whose condition is unstable or highly dysfunc-
• Acute and Specialty Inpatient Care. Section 5C
measures indicators of depression care provided in
inpatient settings and on the transition back to
the community.
13
We chose the indicators in this chapter to reflect the
Plan (OHIP); National Ambulatory Care Reporting
overarching objectives set by the Ontario MOHLTC (see
System (NACRS); Ontario Drug Benefit (ODB) database;
Exhibit 2.3 in the POWER Study Framework, chapter 2).
ICES Physician Database (IPDB); ICES Mother-Baby
Appendix 5.1 indicates which of the Ontario Health
Linked database (MOMBABY) and Statistics Canada
Quality Council’s nine attributes of a high performing
2001 Census. A complete list of the indicators reported
health system each indicator assesses and also which of
in this chapter and their data sources can be found in
the strategic objectives included in the Ontario MOHLTC
Appendix 5.2.
strategy map would be met through improvement on
each indicator.
All indicators are reported at the provincial level and
at the Local Health Integration Network (LHIN) level
We used multiple data sources in this report including
when sample size allowed. All analyses were stratified
the Canadian Community Health Survey (CCHS), Cycle
by sex (where applicable) and then by income, age or
1.1 (2000/01); Daily Census Summary Report Mental
rural/urban residency. Age-adjustment was done using
Health Beds online, MOHLTC Health Data Branch;
indirect standardization. Appendix 5.3 provides a brief
Canadian Institute for Health Information Discharge
description of the research methods.
Abstract Database (CIHI-DAD); Ontario Health Insurance
Measuring Depression
In this chapter, we used population survey data and
series of questions is used to calculate the predicted
health administrative data to discover whether there
probability of major depressive episodes occurring
were sex disparities or other disparities in the treatment
within the year preceding the interview.57 Respondents
of depression in Ontario. Since these data were not
whose predicted probability score was 0.9 or greater
specifically created to answer our questions and also
were considered to have probable depression. However,
because they gathered different kinds of information,
this scale was never fully validated, so rates reported
we had to use different definitions for depression
here may differ from actual population prevalence (see
depending on which data were used.
Appendix 5.3 for more detail).
According to the Diagnostic and Statistical Manual
Physician visit for depression, hospital
Version IV (DSM-IV), a major depressive episode is a
period of two weeks or more with persistent depressed
mood and loss of interest or pleasure in normal activities,
accompanied by symptoms such as decreased energy,
changes in sleep and appetite, impaired concentration
and feelings of guilt, hopelessness or suicidal thoughts.
For this chapter, we used the following definitions:
system to tell us how many people had a physician
visit for depression or a hospital stay for depression.
Physician visits for depression included visits with an
OHIP diagnostic code for depression (311) or reactive
defined as hospitalizations where the most responsible
diagnosis was an ICD-10 code for major depression (see
The Canadian Community Health Survey (CCHS),
Cycle 1.1 uses the Composite International Diagnostic
14
We used data routinely collected by the health care
depression (300). Hospital stays for depression were
Probable depression:
Interview-Short Form for Major Depression. This
stay (hospitalization) for depression:
Appendix 5.2 and Appendix 5.3 for more detail on the
data sources and definitions).
Depression | List of Exhibits
List of Exhibits
Section 5A
Background Measures—the Need, Use and Supply
Exhibit 5A.10 Summary of rural/urban residency
differences (rural-to-urban ratios and 95% confidence
intervals) in background measures of need for and use
of depression care, by sex, in Ontario..........................34
Exhibit 5A.1 Age-standardized prevalence of probable
depression in Ontarians aged 15 and older, by sex and
neighbourhood income quintile, 2000/01................. 23
Exhibit 5A.11 Numbers of GP/FPs and psychiatrists per
100,000 population aged 15 and older, by physician
type and Local Health Integration Network (LHIN), in
Ontario, 2005/06........................................................ 36
Exhibit 5A.2 Prevalence of probable depression
in Ontarians aged 15 and older, by Local Health
Integration Network (LHIN), 2000/01..........................24
Exhibit 5A.12 Number of psychiatric beds per
100,000 population aged 15 and older, by Local Health
Integration Network (LHIN), in Ontario, 2005/06....... 37
Exhibit 5A.3 Sex differences (women-to-men ratios and
95% confidence intervals) in measures of self-reported
health and functioning among individuals with probable
depression, in Ontario, 2000/01..................................26
Exhibit 5A.13 Treatment rates and costs associated
with depression and core mental health care use in
Ontarians aged 15 and older, by measure and Local
Health Integration Network (LHIN), 2005/06...............38
of Health Care Services for Mental Health
Exhibit 5A.4 Age-standardized rate (per 100,000
population) of hospitalizations for depression
in Ontarians aged 15 and older, by sex and
neighbourhood income quintile, 2005/06...................27
Exhibit 5A.5 Age-standardized percentage of Ontarians
aged 15 and older who had an Ontario Health
Insurance Plan (OHIP) core mental health visit, by sex
and neighbourhood income quintile, 2005/06............29
Exhibit 5A.6 Age-standardized Ontario Health
Insurance Plan (OHIP) core mental health care costs
per capita, by sex and neighbourhood income quintile,
in Ontario, 2005/06....................................................30
Exhibit 5A.7 Age-standardized rate (per 100,000
population) of electroconvulsive therapy (ECT) users
in Ontarians aged 15 and older, by sex and
neighbourhood income quintile, 2005/06................. 31
Exhibit 5A.8 Summary of sex differences (womento-men ratios and 95% confidence intervals) in
background measures of need for and use of
depression care, in Ontario.......................................32
Exhibit 5A.9 Summary of neighbourhood income
differences (lowest-to-highest neighbourhood
income quintile ratios and 95% confidence intervals)
in background measures of need for and use of
depression care, in Ontario.......................................33
Section 5B
Primary and Specialty Outpatient Care
Exhibit 5B.1 Age-standardized percentage of Ontarians
aged 15 and older with probable depression who had
a physician visit for depression, by sex and annual
household income, 2000/01.......................................43
Exhibit 5B.2 Percentage of Ontarians aged 15 and
older with probable depression who had a physician
visit for depression, by sex and age group, 2000/01.....43
Exhibit 5B.3 Age-standardized percentage of Ontarians
aged 15 and older with probable depression who had
a physician visit for depression, by sex and rural/urban
residency, 2000/01.....................................................44
Exhibit 5B.4 Age-standardized percentage of
adults aged 66 and older, starting a new course of
antidepressants who had three or more physician
visits for depression within 12 weeks of starting
medication, by sex and neighbourhood income
quintile, in Ontario, 2005/06......................................46
Exhibit 5B.5 Percentage of adults aged 66 and older,
starting a new course of antidepressants who had
three or more physician visits for depression within 12
weeks of starting medication, by sex and age group, in
Ontario, 2005/06........................................................47
15
Exhibit 5B.6 Percentage of adults aged 66 and older,
starting a new course of antidepressants who had three
or more physician visits for depression within 12 weeks
of starting medication, by Local Health Integration
Network (LHIN), in Ontario, 2005/06..........................48
Exhibit 5B.7 Age-standardized percentage of women
who had a physician visit for depression within one year
of giving birth by neighbourhood income quintile, in
Ontario, 2005/06........................................................49
Section 5C
Acute and Specialty Inpatient Care
Exhibit 5C.1 Age-standardized percentage of patients
aged 15 and older admitted to hospital for depression
who had a physician visit for depression within 30
days of discharge, by sex and neighbourhood income
quintile, in Ontario, 2005/06..................................... 54
days of discharge, by sex and rural/urban residency, in
Ontario, 2005/06........................................................55
Exhibit 5C.3 Percentage of patients aged 15 and
older admitted to hospital for depression who had
a physician visit for depression within 30 days of
discharge, by Local Health Integration Network (LHIN),
in Ontario, 2005/06....................................................56
days of discharge, by sex and Local Health Integration
Network (LHIN), in Ontario, 2005/06 ........................ 57
Exhibit 5C.5 Percentage of patients aged 15 and older
who had a post-discharge physician visit for depression,
by sex and time from discharge, 2005/06....................58
Exhibit 5C.6 Mean number of days to a first
physician visit for depression in patients aged
15 and older admitted to hospital for depression,
by sex and neighbourhood income quintile, in
Ontario, 2005/06........................................................59
16
Exhibit 5C.7 Mean number of days to a first physician
visit for depression in patients aged 15 and older
admitted to hospital for depression, by sex and age
group, in Ontario, 2005/06 ...................................... 60
aged 15 and older hospitalized for depression
who were seen in an emergency department (ED)
within 30 days of discharge without a subsequent
hospitalization, by sex and neighbourhood income
quintile, in Ontario, 2005/06....................................61
older hospitalized for depression who were seen in
an emergency department (ED) within 30 days of
discharge without a subsequent hospitalization, by
sex and age group, in Ontario, 2005/06...................62
older hospitalized for depression who were seen in an
emergency department (ED) within 30 days of discharge
without a subsequent hospitalization, by Local Health
Integration Network (LHIN), in Ontario, 2005/06.........63
aged 15 and older hospitalized for depression who
were seen in an emergency department (ED) within 30
days of discharge without a subsequent hospitalization,
by sex and Local Health Integration Network (LHIN), in
Ontario, 2005/06 ..................................................... 64
Exhibit 5C.12 Age-standardized 30-day readmission
rate (percentage) for depression among patients aged 15
and older admitted to hospital for depression, by sex and
neighbourhood income quintile, in Ontario, 2005/06..... 65
Exhibit 5C.13 30-day readmission rate (percentage) for
depression among patients aged 15 and older admitted
to hospital for depression, by Local Health Integration
Network (LHIN), in Ontario, 2005/06 ........................ 66
Exhibit 5C.14 Age-standardized 30-day readmission
rate (percentage) for depression among patients aged
15 and older admitted to hospital for depression, by
sex and Local Health Integration Network (LHIN), in
Ontario, 2005/06.....................................................67
Depression | List of Exhibits
17
A Guide to Reading Maps
Maps are the main visual representation of spatial patterns of
data and analyses covered in this Report.
Ontario is difficult to map as a province, due to its
The main feature to look for is the height of the bars,
vast areas in the North and detailed characteristics in
since it represents the value of the mapped attribute. The
the South. As such, all maps consist of three views—
larger the attribute number (relative risk, odds ratio or
Northern Ontario, Toronto and surrounding areas, and
rate), the taller the bar. The number at the top or beside
Southern Ontario. The measures of distance and area on
each bar represents the actual value of the attribute.
these views differ from one another.
If the attribute is presented in two subgroups (e.g.,
There are two types of thematic maps in this Report that
women and men) as in Figure 2, then each LHIN area on
depict a magnitude of analyzed variables: 1) bar chart
the map has two bars. When the attribute is presented
maps and 2) choropleth (shaded) maps. The following
in four subgroups (e.g., lower-education women, higher-
descriptions aim to help the reader correctly view and
education women, lower-education men, and higher-
interpret these two map types.
education men) as in Figure 3, then each LHIN area on
the map has four bars. In all cases, the height of the bar
Bar Chart Maps
is proportional to the value of the mapped attribute.
Bar chart maps can depict a variety of numeric variables
In the legend of the map the top set of bars reflects the
including counts and ratios across Local Health
highest observed value in the depicted data set. This can
Integration Networks (LHINs) in Ontario. In most of the
be used for visual comparison with the bars on the map.
maps in this Report, the bars show values of relative risks,
odds ratios or rates (percentages).
The bottom set of bars shows the overall Ontario values
of the depicted attributes and can be also compared
visually to the bars on the map.
Figure 2: Example of a Two Bar Map
Northern
Ontario
H U D S
O N
Figure 3: Example of a Four Bar Map
B
38
13
16
14
Overall Ontario
L A K E
N I P I G O N
In Ontario, 34% of lower-income women, 25% of
Thunder
Bay 30% of lower-income men
higher-income
women,
and 23% of higher-income men reported having
Nactivity limitations. E S U P E R I O
K
R
L A
0
30
34%
18
500 Km
28*
26
Thunder Bay
25%
23%
¥Activities at home, school or work that have been limited due to a long-term
physical condition, mental condition or health problem
Toronto and surrounding areas
13
43
34
L A K E
N I P I G O N
30%
Note: See Appendix 3.3 for definitions of annual household income categories
250
36
23
Sudbury
me categories
A
14
32
18%
B
Y
28
H U D S
O N
Northern
Ontario
A
Y
%
K E
L A
N
24
24
S U P E R I
O R
Sudbury
0
250
500 Km
Depression | Reading Maps
Overall Ontario
L A K E
N I P I G O N
Choropleth
(shaded) maps
Frutiger 65 bold.
Thunder Bay
Choropleth maps use different shades or 17%
colours to
proportional to a larger data value—the larger the
depict data values. Each colour generally represents
R I
K
O shade or colour on the map.
data value, theL Adarker
the
R
E
S U P E
Sudbury
Shaded maps usually represent rate or ratio
variables
set inof
Frutiger
55 Roman
a Notes
range
values,
as shown in the map legend. In
0
general, the darkness of the shade or colour is
250
Km
rather
than 500
raw
counts or amounts.
*extra note line set in Frutiger 55 Roman
Figure 4: Example of a Choropleth Map
13
11
Ottawa
9
12
Barrie
L
2
A
Peterborough
5
3
8
K
Markham
Kingston
Southern
Ontario
E
e
Orangeville
R O N
H U
6
Kitchener
7
Toronto
Mississauga
K E
L A
O N T A R I O
0
50
100 Km
Hamilton
1
4
London
Windsor
10
K E
L A
30-day mortality rate (%)
11-12
13-14
15-16
17-18
19-20
E R I E
19
20
Depression | Section 5A
Section 5A
Background Measures—the Need, Use
and Supply of Health Care Services for
Mental Health
Introduction
This section provides a snapshot of the need for and use of health
care services for mental health in Ontario. In an equitable world
with limitless resources, use of health services would match need
regardless of factors such as sex, income and geography.
This section gives the broad context necessary to
Although the data are from different sources and were
understand and interpret indicators of depression care
gathered at different times for different purposes, they
described later in this chapter.
show remarkable consistency.28, 61, 62 We have divided
We looked at need (including the prevalence of
depression and the health and functional status of
people living with it), use of services (including physician
visits, hospitalizations, treatments received and cost)
and supply of medical services (including financial and
human resources) for depression and mental health
care. Some of these measures focus specifically on
depression and depression care. Others, such as the
supply and cost measures, relate to mental health in
general and were based on definitions used in previous
Ontario reports.58-60
The prevalence of depression varies by gender and
socioeconomic status as do barriers to accessing
them into four subsections:
Measures of Need: Prevalence, Health and
Functional Status
• Prevalence of probable depression
• Among people with probable depression:
– The percentage who rated their health as fair or poor
– The percentage who reported no other comorbid
chronic medical conditions
– The average number of days in the past two weeks out
of bed for all or most of the day
– The average number of days in the past two weeks
without cutting down on normal activities
services for depression care and patterns of use.8-11
Measures of Use: Treatment and Cost
The supply of services such as the number of primary
• Number of individuals using OHIP core mental health
care physicians, psychiatrists and hospital beds per
capita vary across communities.58 These factors all
contribute to the cost of depression care.
services per 100,000 population
• OHIP core mental health services costs per capita
• Hospitalization rates for depression per
100,000 population
21
• Number of individuals who received electroconvulsive
therapy (ECT) per 100,000 population
• Number of psychiatrists per 100,000 population
• Number of acute hospital psychiatric beds per
100,000 population
Measures of Supply: Financial and
Human Resources
• Number of general practitioners (GPs) or family practice
physicians (FPs) per 100,000 population
Patterns of Need, Use and Supply
• Geographic patterns of use were examined with the goal
of comparing them to the patterns of need and supply
Interpreting Risk Ratios
In this section we present a number of risk ratio figures.
interval from 0.5 to 1.5 contains 1.0), this is interpreted
Risk ratios estimate the likelihood that an event (e.g.,
as the two groups not being different in terms of their
having probable depression) occurring in one group is
likelihood of having the event.
the same or different from the likelihood of the event
occurring for another group. A ratio of 1.0 indicates
that the likelihood for the two groups is equal (or very
close to equal). A ratio that is less than 1.0 (e.g., 0.5)
indicates that the likelihood is lower for the first group
compared to the second, while a ratio greater than
For example in Exhibit 5A.8 the risk ratio for probable
depression in women compared to men is 1.98. This
means that women are 1.98 times (or twice) as likely to
have probable depression as men. The 95% confidence
interval is (1.74, 2.24). This means that taking into
account variation due to sampling, we can have 95%
1.0 indicates that it is higher. For each risk ratio, we
also provide 95% confidence intervals to estimate the
uncertainty associated with the ratio. If the value of 1.0
occurs within a confidence interval (e.g., a confidence
certainty that the true value lies within this range.
Because the lower value is greater than one, we can
say that women have a higher prevalence of probable
depression than men.
1.98
Prevalence of probable
depression (percentage)^
0.5
1.0
1.5
2.0
2.5
POWER Study
22
EXHIBITS AND FINDINGS
Measure of need: Prevalence of probable depression
Measure: This measure assesses the percentage of Ontarians aged 15 and older with probable depression in 2000/01.
Background: Worldwide, major depression is a leading cause of disability and the third leading cause of burden of
disease as measured in disability-adjusted life years (DALYS—the years of potential life lost because of early death,
plus the years of productive life lost because of the disability).63 Mood disorders (of which depression is the most
common) have a major economic impact because of both health care costs and lost productivity. Because they are
so common, cause suffering, pose a risk of suicide, reduce quality of life and have a large impact on the economy,
mood disorders are a serious public health concern in Canada. This measure is based on data from the Canadian
Community Health Survey (CCHS), Cycle 1.1 which measures depression using the Composite International
Diagnostic Interview-Short Form (CIDI-SF) for Major Depression. This series of questions is used to calculate the
predicted probability of major depressive episodes occurring within the year preceding the interview.57 Respondents
whose predicted probability score was 0.9 or greater were considered to have probable depression. However, this
scale was never fully validated, so rates reported here may differ from actual population prevalence.
Findings: In Ontario, in 2000/01, 7.4 percent of people aged 15 and older met the criteria for having probable
depression. Women were more likely than men to have probable depression (9.8 percent versus 4.9 percent, respectively).
EXHIBIT 5A.1 | A
ge-standardized prevalence of probable depression in Ontarians
aged 15 and older, by sex and neighbourhood income quintile, 2000/01
FINDINGS
•The prevalence of depression varied by
income for women and men. Rates were
highest among those living in the lowestincome neighbourhoods (11.8 percent of
women and 5.5 percent of men) compared
to those living in the highest-income
neighbourhoods (8.5 percent of women
and 4.2 percent of men).
•The income difference in the prevalence
of probable depression was significant for
women but not for men.
Percentage (%)
•Women were twice as likely as men to
have probable depression, regardless of
neighbourhood income.
25
20
15
11.8
10.5
10
5
0
5.5
Q1
(lowest)
9.5
8.9
5.4
Q2
4.4
Q3
8.5
5.0
Q4
4.2
Q5
(highest)
Neighbourhood income quintile
Women
Men
Data sources: Canadian Community Health Survey (CCHS), Cycle
1.1; Statistics Canada 2001 Census
Note: See Appendix 5.3 for details about neighbourhood income
quintile calculation
POWER Study
23
EXHIBIT 5A.2 | P
revalence of probable depression in Ontarians^ aged 15 and older,
by Local Health Integration Network (LHIN), 2000/01
FINDINGS
•Sex differences in the prevalence of
probable depression at the LHIN level
were not reported because of small
sample sizes in a number of LHINs. In those
LHINs with adequate sample sizes, twice
as many women as men had probable
depression, consistent with the overall
provincial pattern.
•After adjusting for age, prevalence of
depression remained quite similar to
the unadjusted rates, ranging from 5.1
percent in the Central East LHIN to 9.2
percent in the Toronto Central LHIN. The
pattern across LHINs also did not change
after adjusting for age (data not shown).
Percentage (%)
•There was significant regional variation in
the prevalence of depression, from a low
of 5.2 percent in the Central East LHIN to
9.3 percent in the Toronto Central LHIN.
25
20
15
10
7.2
6.5
1
2
8.9
8.4
5
0
8.7
9.3
5.8
3
4
5
6
7
6.0
5.2
8
9
7.4 7.9
8.0
8.2
10
12
13
11
7.0
14
Local Health Integration Network (LHIN)
1. Erie St. Clair
8. Central
2. South West
9. Central East
3. Waterloo Wellington
4. Hamilton Niagara Haldimand Brant
10. South East
11. Champlain
5. Central West
12. North Simcoe Muskoka
6. Mississauga Halton
13. North East
7. Toronto Central
14. North West
Data sources: Canadian Community Health Survey (CCHS), Cycle 1.1
^ Brant region did not participate in the depression module of CCHS,
Cycle 1.1
POWER Study
24
MEASUREs OF NEED: Health and Functional Status
Measures: The following measures assess the health and functional status of Ontarians aged 15 and older with
probable depression:
• The percentage who rated their health as fair or poor
• The percentage who reported no other comorbid chronic medical conditions
• The average number of days in the past two weeks out of bed for all or most of the day—that is not confined to bed
due to illness, injury or hospitalization
• The average number of days in the past two weeks without cutting down on normal activities due to illness or injury.
Background: Prevalence rates provide information about only one dimension of need.64 Need is also influenced by
a person’s general health, the severity of her/his functional impairment and any other health problems or comorbidities. Many people who have depression also have other comorbid chronic medical conditions. These coexisting
illnesses or comorbidities may influence treatment choice and outcomes of depression care. Conversely, untreated
depression can lead to worse outcomes for comorbid chronic medical conditions. The number of days a person
with depression does not remain in bed or does not need to cut down on their normal activities is a measure of
how well they are able to function.
Findings: Among individuals with probable depression in Ontario:
• 29 percent reported their health as fair or poor (27 percent of women and 32 percent of men), compared to 13
percent of women and men aged 25 and older in the general population (see Burden of Illness, chapter 3).
• 67 percent reported that they had at least one comorbid chronic medical condition in addition to depression (69
percent of women and 62 percent of men); in other words, only 33 percent reported having no comorbid chronic
medical conditions.
• The average number of days in the previous two weeks when they were out of bed was 13 (13 days for both women
and men).
• The average number of days in the previous two weeks when they did not have to cut down on normally activities
was 12 (12 days in women and 13 days in men).
25
EXHIBIT 5A.3 | S ex differences (women-to-men ratios and 95% confidence intervals)
in measures of self-reported health and functioning among
individuals with probable depression, in Ontario, 2000/01
0.87
Percentage rating own
health as fair or poor
0.81
Percentage with no other
comorbid chronic medical conditions
1.00
Average number of days out
of bed in past two weeks
0.99
Average number of days without
cutting down on normal activities
in past two weeks
0.5
1.0
1.5
2.0
Women-to-men ratio
Data SOURCE: Canadian Community Health Survey (CCHS), Cycle 1.1
Note: See ‘Interpreting Risk Ratios’ box in the Introduction of Section 5A
FINDINGS
•Women with probable depression were significantly less likely than men to report having no other
comorbid chronic medical conditions.
•There were no differences between women and men with probable depression in how they rated their
own health or ability to function.
•Among people with probable depression, health and functional status did not vary by neighbourhood
income or Local Health Integration Network (LHIN) (data not shown).
POWER Study
26
Measure of Use: Rate of hospitalization for depression
Measure: This descriptive measure reports the number of hospitalizations for depression per 100,000 population
aged 15 and older.
Background: Although most individuals with mood disorders (including depression) are treated in the community,
hospitalization is sometimes necessary. Serious depressions may require hospitalization, with follow up medical
attention or monitoring. High rates of hospitalization may signal a problem in how mental health services are
delivered and integrated—good community care can prevent hospitalization. Ontario’s policy for the past three
decades has been to provide care in the least restrictive setting65 with inpatient care being part of a network of
physician, community and social support services that aim to keep patients in the community.
Findings: In Ontario, the rate of hospitalization for depression for the period from March 1, 2005 to February 28,
2006 was 108 per 100,000 population aged 15 and older: 127 per 100,000 women and 87 per 100,000 men.
EXHIBIT 5A.4 | A
ge-standardized rate (per 100,000 population) of hospitalizations
for depression in Ontarians aged 15 and older, by sex and
neighbourhood income quintile, 2005/06^
FINDINGS
•Lower-income women and men were
more likely to be hospitalized for
depression, with the rate in the
lowest-income quintile nearly twice
the rate for the highest-income quintile
(178 versus 97 per 100,000 for women;
124 versus 68 per 100,000 for men).
Rate per 100,000
•Women had higher rates of
hospitalization than men, regardless
of neighbourhood income.
200
150
178
148
124
122
105
98
100
76
97
71
68
50
0
Q1
(lowest)
Q2
Q3
Q4
Q5
(highest)
Women
Men
Data sources: Canadian Institute for Health Information Discharge
Abstract Database (CIHI-DAD); Statistics Canada 2001 Census; Registered
Persons Database (RPDB)
^ People who were discharged from hospital from Mar 1, 2005 Feb 28, 2006
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27
MEASURES OF USE: Ontario Health Insurance Plan (OHIP) core
mental health care users and OHIP core mental health care
costs per capita
Measures: Two measures were used to assess the use of OHIP core mental health services:
• The proportion of Ontarians aged 15 and older who used OHIP physician services for mental health (assessment,
diagnosis or treatment)
• The average cost (in 2005 Canadian dollar equivalents (CAD)) per capita paid for these core mental health services
Background: Household surveys in Canada and Ontario consistently report that the majority of mental health care
reported by survey respondents has been received from general practitioners and family physicians with the next
largest source of care being psychiatrists (of people who use mental health services, approximately 60-75 percent
receive care from general practitioners and approximately 25-40 percent receive care from psychiatrists).11, 66, 67
This fits with the view of the family doctor as the gatekeeper of the health care system where access to specialist
care is by referral and all care is coordinated through a frontline provider. In Ontario, the most complete data
source for both general and specialty physician care is the OHIP claims database.
Findings: In Ontario, 15 percent of the population aged 15 and older used OHIP core mental health services
including psychiatric assessment, diagnosis or treatment in the course of one year (18 percent of women and 11
percent of men). The average cost paid for these services was $33 (CAD) per capita ($41 (CAD) for women and
$24 (CAD) for men).
28
EXHIBIT 5A.5 | A
ge-standardized percentage of Ontarians aged 15 and older who
had an Ontario Health Insurance Plan (OHIP) core mental health
visit,^ by sex and neighbourhood income quintile, 2005/06†
FINDINGS
•Low-income women and men were
somewhat more likely to use core mental
health services; however, these differences
were very small.
50
Percentage (%)
•Almost twice as many women as men used
OHIP core mental health services, regardless
of neighbourhood income.
40
30
20
19
10
0
18
18
12
Q1
(lowest)
11
Q2
18
11
Q3
18
10
Q4
10
Q5
(highest)
Women
Men
Data sources: Ontario Health Insurance Plan (OHIP); Statistics Canada
2001 Census; Registered Persons Database (RPDB)
^ Based on fee-for-service OHIP billings for assessment, diagnosis
or treatment
† People who accessed services from Mar 1, 2005 - Feb 28, 2006
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29
FINDINGS
•Consistent with their higher rates of
physician visits for OHIP core mental health
services, women also incurred higher OHIP
core mental health care costs per capita
than men, regardless of neighbourhood
income.
Cost per capita (CAD)
EXHIBIT 5A.6 | A
ge-standardized Ontario Health Insurance Plan (OHIP) core
mental health care costs^ per capita, by sex and neighbourhood
income quintile, in Ontario, 2005/06†
100
•OHIP costs for core mental health services
varied by neighbourhood income. Women
and men living in the highest-income
neighbourhoods had significantly higher
OHIP costs than individuals living in lowerincome neighbourhoods.
80
60
40
40
40
25
20
0
Q1
(lowest)
48
39
23
Q2
39
22
Q3
29
22
Q4
Q5
(highest)
Women
Men
^ Based on fee-for-service OHIP billings for assessment, diagnosis
or treatment
† People who accessed services from Mar 1, 2005 - Feb 28, 2006
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30
MEASURE OF USE: Electroconvulsive therapy (ECT) use
Measure: This measure reports the number of electroconvulsive therapy (ECT) users per 100,000 population aged
15 and older.
Background: Electroconvulsive therapy has been found to be effective for individuals with severe and treatmentresistant forms of depression.68, 69 It is also used to treat other severe mental illnesses such as bipolar disorder and
schizophrenia, but more as an alternative to first-line treatment options.69
Findings: In Ontario, the number of ECT users was 15 people per 100,000 population aged 15 and older. The rate
was significantly higher in women than in men: 18 per 100,000 versus 11 per 100,000, respectively.
EXHIBIT 5A.7 | A
ge-standardized rate (per 100,000 population) of electroconvulsive
therapy (ECT) users in Ontarians aged 15 and older, by sex and
neighbourhood income quintile, 2005/06^
FINDINGS
•Women living in lower-income
neighbourhoods were somewhat more
likely to receive ECT than those living in
higher-income neighbourhoods.
Rate per 100,000
•Women were more likely than men to
receive ECT, regardless of neighbourhood
income quintile.
50
40
30
20
20
20
12
13
16
9
10
0
Q1
(lowest)
Q2
16
Q3
17
12
Q4
11
Q5
(highest)
Women
Men
^ People who accessed services from Mar 1, 2005 - Feb 28, 2006
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31
EXHIBIT 5A.8 | S ummary of sex differences (women-to-men ratios and 95%
confidence intervals) in background measures of need for and
use of depression care, in Ontario
1.98
1.45
Rate of hospitalization for
depression per 100,000†
1.69
OHIP core mental health service
users (percentage)¥‡
1.70
OHIP core mental health
costs per capita (CAD)¥‡
1.61
Electroconvulsive therapy
users per 100,000¥
0.5
1.0
1.5
Women-to-men ratio
2.0
2.5
Data sources:
^Canadian Community Health Survey (CCHS), Cycle 1.1, 2000/01
†Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD), Mar 1, 2005 - Feb 28, 2006;
Registered Persons Database (RPDB)
¥Ontario Health Insurance Plan (OHIP), Mar 1, 2005 - Feb 28, 2006; RPDB
‡Extremely narrow confidence intervals
Note: See ‘Interpreting Risk Ratios’ box in the Introduction of Section 5A
FINDINGS
•Women were almost twice as likely as men (risk ratio - 1.98) to have probable depression.
•The pattern of service use was similar to the prevalence pattern. Women were consistently and
significantly more likely than men to use both OHIP core mental health services and those more specific
to the care of depression (hospitalization for depression and ECT use).
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32
EXHIBIT 5A.9 | S ummary of neighbourhood income differences (lowest-to-highest
neighbourhood income quintile ratios and 95% confidence
intervals) in background measures of need for and use of
depression care, in Ontario
1.36
1.83
Rate of hospitalization for
depression per 100,000†
1.09
OHIP core mental health service
users (percentage)¥‡
OHIP core mental health
costs per capita (CAD)¥‡
0.85
1.16
Electroconvulsive therapy
users per 100,000¥
0.5
1.0
1.5
2.0
2.5
Lowest-to-highest neighbourhood income ratio
Data sources:
Statistics Canada 2001 Census
†Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD), Mar 1, 2005 - Feb 28, 2006;
¥Ontario Health Insurance Plan (OHIP), Mar 1, 2005 - Feb 28, 2006; RPDB
Notes: See Appendix 5.3 for details about neighbourhood income quintile calculation
See ‘Interpreting Risk Ratios’ box in the Introduction of Section 5A
FINDINGS
•Lowest-income neighbourhoods had a significantly higher prevalence of probable depression than
highest-income neighbourhoods (risk ratio - 1.36).
•Women and men living in the lowest-income neighbourhoods were also somewhat more likely to use
OHIP core mental health services and to receive ECT and much more likely to be hospitalized
for depression.
•However, individuals living in the lowest-income neighbourhoods accounted for lower OHIP core mental
health care costs, which suggests they either made fewer visits or received less expensive services than
those living in the highest-income neighbourhoods.
•The effect of neighbourhood income was similar for women and men for use and cost measures of
depression care (data not shown).
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33
EXHIBIT 5A.10 | S ummary of rural/urban residency differences (rural-to-urban
ratios and 95% confidence intervals) in background measures of
need for and use of depression care, by sex, in Ontario
0.93
Prevalence of probable depression
(percentage)^
0.85
1.29
Rate of hospitalization for depression
per 100,000†
1.44
0.91
OHIP core mental health services users
(percentage)¥
0.83
0.60
OHIP core mental health costs per capita
(CAD)¥
0.56
0.80
Electroconvulsive therapy users per capita
100,000¥
0.81
0.5
1.0
1.5
2.0
2.5
Rural-to-urban ratio
Women
Men
Data sources:
†Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD), Mar 1, 2005 - Feb 28, 2006
¥Ontario Health Insurance Plan (OHIP), Mar 1, 2005 - Feb 28, 2006
Notes: See Appendix 5.3 for details about rural/urban residency calculation
See ‘Interpreting Risk Ratios’ box in the Introduction of Section 5A
FINDINGS
•The prevalence of probable depression was similar in rural and urban regions.
•Women and men from rural areas were less likely to have had OHIP core mental health visits but
were more likely to have been hospitalized for depression than those living in urban areas.
•Women and men from rural areas also incurred lower OHIP core mental health costs per capita.
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34
MEASURES OF SUPPLY: FINANCIAL AND HUMAN RESOURCES
Measures: Three measures of supply of medical services for mental health care are explored:
• Number of general practitioners (GPs) or family practice physicians (FPs) per 100,000 population
• Number of psychiatrists per 100,000 population
• Number of acute hospital psychiatric beds per 100,000 population
Background: Most Canadians receive their medical mental health care through visits to family physicians and
psychiatrists.11, 66, 67 A much smaller percentage receive care in walk-in clinics, community mental health agencies,
case management and crisis teams, emergency departments and inpatient hospital beds.70 The three supply
measures reported here measure the most frequently visited medical providers of mental health care (family
physicians and psychiatrists) and the most costly service (hospital beds).
Findings: In Ontario, there are 105 GP/FPs, 19 psychiatrists and 51 acute hospital psychiatric beds per 100,000 population.
35
Physicians per 100,000
EXHIBIT 5A.11 | N
umbers of GP/FPs^ and psychiatrists per 100,000 population
aged 15 and older, by physician type and Local Health Integration
Network (LHIN), in Ontario, 2005/06
200
168
150
100
102
93
90
98
90
75
72
0
1
17
2
GP/FPs
9
3
14
4
6
5
12
10
6
7
113
102
83
72
50
7
140
135
120
8
21
8
9
10
30
9
11
12
10
13
10
14
Psychiatrists
1. Erie St. Clair
11. Champlain
2. South West
7. Toronto Central
8. Central
13. North East
9. Central East
14. North West
5. Central West
10. South East
Data sources: ICES Physician Database (IPDB); Registered Persons Database (RPDB)
^ GP/FP=General Practitioner/Family Physician
FINDINGS
•There was considerable regional variation in physician supply across Ontario.
•The Toronto Central LHIN had more than twice as many GP/FPs as the Erie St. Clair LHIN
(168 per 100,000 versus 72 per 100,000).
•The Toronto Central LHIN had more than twelve times as many psychiatrists available as the Central
West LHIN (72 per 100,000 versus 6 per 100,000).
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36
EXHIBIT 5A.12 | N
umber of psychiatric beds per 100,000 population aged 15
and older, by Local Health Integration Network (LHIN), in
Ontario, 2005/06
FINDINGS
Beds per 100,000
•There was nearly a three-fold difference in
the number of psychiatric beds available
across the LHINs. The Champlain LHIN had
35 beds per 100,000 population compared
to 10 beds per 100,000 in the Waterloo
Wellington LHIN.
50
40
35
28
30
20
0
27
21
17
10
10
1
2
34
3
4
14
5
26
17
12
11
6
7
8
9
16
15
10
11
12
13
14
1. Erie St. Clair
2. South West
8. Central
9. Central East
10. South East
11. Champlain
5. Central West
13. North East
7. Toronto Central
14. North West
Data sources: Daily Census Summary Report Mental Health Beds
online, MOHLTC Health Data Branch (http://www.mohltcfim.com/cms/
client_webmaster/index.jsp, accessed February 6, 2008); Registered
Persons Database (RPDB)
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37
Patterns of need, use and supply
The geographic variations in three of the descriptive measures of use are presented together with the objective of
comparing them to the geographic patterns of need and supply presented earlier in this section.
80
Rate per 100,000
300
70
250
60
200
50
40
150
30
100
20
50
0
10
1
2
3
4
5
6
†
OHIP core mental health costs¥
7
8
9
10
11
12
13
Costs per capita (CAD)
EXHIBIT 5A.13 | T
reatment rates and costs associated with depression and core
mental health care use in Ontarians aged 15 and older, by measure
and Local Health Integration Network (LHIN), 2005/06^
14
ECT users
¥
1. Erie St. Clair
11. Champlain
2. South West
7. Toronto Central
8. Central
13. North East
9. Central East
14. North West
5. Central West
10. South East
Data sources:
†Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD)
¥Ontario Health Insurance Plan (OHIP)
^People who were discharged from hospital or accessed services from Mar 1, 2005 - Feb 28, 2006
FINDINGS
•The geographic patterns of hospitalizations for depression, electroconvulsive therapy use and cost per
capita for Ontario Health Insurance Plan (OHIP) core mental health services varied considerably and
there was no consistent relationship among these patterns. Some areas with low rates of hospitalization
had high per capita expenditures for core mental health care, others did not.
•The OHIP core mental health care costs per capita align with the supply of physicians shown in an earlier
exhibit (Exhibit 5A.11) while hospitalization rates align with the supply of hospital beds (Exhibit 5A.12).
•However, there was no consistent relationship across the LHINs between OHIP core mental health care
costs or hospitalization rates and the prevalence of probable depression (Exhibit 5A.2).
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38
Section 5A
Summary of Findings
These measures provide a complex backdrop for studying
Use
gender and sociodemographic inequities in need and
• There were distinct sex differences in use of services for
access to mental health care. We found, consistent with
depression. Women were between one and a half to
the literature, that prevalence of probable depression
two times more likely than men to use OHIP core mental
varied among population subgroups. Women had a
health services—a pattern consistent with their higher
higher prevalence of depression than men and women
rates of depression.
living in the lowest-income neighbourhoods had a higher
prevalence than women living in the highest-income
neighbourhoods. Women with probable depression were
more likely to report comorbid chronic medical conditions
than men. The data on use of Ontario Health Insurance
Plan (OHIP) core mental health services clearly show
differences in access by sex, neighbourhood income and
rural/urban residency. There was sizable regional variation
in supply and use of mental health services.
• Although women from lower-income neighbourhoods
were more likely to have probable depression than those
from higher-income neighbourhoods, they had the same
rate of use of OHIP core mental health services. However,
women from higher-income neighbourhoods incurred
greater OHIP core mental health costs than women from
lower-income neighbourhoods.
• Women and men from lower-income neighbourhoods were almost twice as likely to be hospitalized for
More information on the match between individual need
depression but incurred slightly lower average costs for
for depression care and OHIP visits for depression follows
OHIP mental health services than those from higher-
in Sections 5B and 5C of this chapter.
income neighbourhoods.
Need
• Women were twice as likely to have probable depression
as men in Ontario.
• There were regional and income differences in the
• Rural and urban residents used services differently.
Rural residents were more likely to be hospitalized for
depression, while urban dwellers had higher per capita
OHIP costs for mental health care.
prevalence of probable depression. Individuals living in
Supply
the lowest-income neighbourhoods were more likely
• Resources such as physician supply and psychiatric
to have probable depression than those living in the
hospital beds varied markedly across Local Health
highest-income neighbourhoods.
Integration Networks (LHINs). The differences between
• There were no differences in the prevalence of probable
the highest and lowest rates per 100,000 population
depression between people who were living in rural and
among LHINs ranged from twice as many GPs to three
urban areas.
times as many hospital beds and 12 times as many psy-
• Women with probable depression were somewhat more
chiatrists.
likely to report comorbid chronic medical conditions
Patterns of Need, Use and Supply
than men. However, there were few differences by sex
• Patterns of service use reflected supply more than need.
in self-rated health or self-reported functioning among
those with probable depression.
39
Section 5B
Primary and Specialty Outpatient Care
Prevention/
health
promotion
Community
services/
supports
Primary
care
Specialty
outpatient
care
Acute
hospital
care
Specialty
hospital
care
Introduction
Along the continuum of depression care, primary care and
specialty outpatient care play a critical role. Primary and
specialty outpatient care providers identify and diagnose
depression and provide treatment that improves mental
health and prevents recurrence of the condition.
Early, equitable assessment and treatment are important
People with depression often go untreated2-5 and other
because the costs of depression are high. Untreated
studies suggest that some receive suboptimal care.6, 7
depression results in poor functional status and disability
However, there is growing evidence that a number of
among women and men with the disease. It can also lead
interventions do improve the quality and outcomes of
to high costs to the health system and society because
depression care.12-14, 72 Furthermore, there are well-
suboptimal diagnosis and treatment lead to costly and
validated indicators that measure the quality of depression
potentially preventable expenses including avoidable
care which are in use internationally.73
hospitalizations and lost productivity. In the previous
section we showed that women were more likely to be
depressed and also more likely to seek medical care for
mental health problems. Although the medical literature
shows gender differences in how women and men seek
help and their reported barriers to care, those issues are
In this section we focus on depression care provided
in primary and specialty outpatient settings, which are
the most frequent source of overall mental health care
reported in North American household surveys,74-76
including Ontario surveys.77
beyond the scope of this chapter.71 In this section, we
We examined three indicators specific to outpatient
look more specifically at the quality of care for depression
treatment for depression to assess whether there were
in outpatient settings and try to determine whether there
gender disparities in depression care; and whether there
are sex differences in the delivery of that care.
were disparities among women and men associated
40
Depression | Section 5B
with income and age in access to or quality of care in
care because of some limitations with Ontario Health
the province. They are:
Insurance Plan (OHIP) data. Only one diagnostic code
• Percentage of people with probable depression who
had a physician visit for depression
• Percentage of patients, aged 66 and older, who filled
can be recorded in the OHIP database per patient
visit, therefore, a person with depression plus another
condition may have her/his visit coded as the other
condition instead of depression, leading to under-
and continued a new prescription for antidepressant
counting. Also, one of the two codes related to depression
medication and who had at least three physician visits for
(OHIP diagnostic code, 300) combines it with other mental
depression in the 12 weeks after starting antidepressants
health conditions such as anxiety. Since this is also the
• Percentage of women who had given birth who had
code most frequently used by family doctors, this leads
a physician visit for depression within one year
to over-counting of physician visits for depression (see
following delivery.
Appendix 5.3 for more detail).78 However, when the
The definition of a physician visit for depression in this
chapter is imprecise and may either under- or overestimate the number of physician visits for depression
definition is tied to a person with probable depression or
a prescription for an antidepressant, it may more closely
indicate a visit where depression was addressed.
41
Percentage of individuals with probable depression who had a
physician visit for depression
Indicator: This indicator measures the percentage of individuals, aged 15 and older, with probable depression who
had a physician visit for depression in the year after being interviewed for a health survey (Canadian Community
Health Survey (CCHS), Cycle 1.1).
Background: Depression is a treatable condition and high quality care for depression leads to improved patient
outcomes. Having a physician visit for depression is often the first step towards receiving this care. The best
measures of population need for depression care come from household surveys such as the CCHS, Cycle 1.2 or the
World Mental Health 2000 surveys developed by the World Health Organization.79, 80 Studies using these measures
find that approximately 50 percent of those who met the survey criteria for major depression in the past year
reported no contact with medical mental health services during that time.81, 82 While it is not clear that everyone
who meets these kinds of survey criteria requires medically provided depression care, it is still certain that there are
many who do not get the treatment they need.77, 83-85
Findings: In Ontario, only 40 percent of people with probable depression (41 percent of women and 37 percent of
men) had at least one physician visit for depression within the year following the CCHS interview.
42
EXHIBIT 5B.1 | A
ge-standardized percentage of Ontarians aged 15 and older with
probable depression who had a physician visit for depression, by sex
and annual household income, 2000/01
FINDINGS
80
Percentage (%)
•Low-income women with probable
depression were significantly more likely
than higher-income women to have had a
physician visit for depression. The income
variation was not significant in men.
100
60
40
51
41
37
41
44
32
38
33
20
0
Low
Lower middle
Middle
Higher
Annual household income
Women
Men
1.1; Ontario Health Insurance Plan (OHIP)
Note: See Appendix 5.3 for definitions of annual household
income categories
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EXHIBIT 5B.2 | P
ercentage of Ontarians aged 15 and older with probable
depression who had a physician visit for depression, by sex and
age group, 2000/01
FINDINGS
•The rate of physician visits for depression
was highest among those aged 45-64 and
lowest among those aged 15-24.
Percentage (%)
•There was no difference in the percentage
of women and men who had a physician
visit for depression, irrespective of age.
100
80
60
40
43
50 47
38
46
28*
27 26*
20
0
15-24
25-44
45-64
65+
Age group (years)
Women
Men
1.1; Ontario Health Insurance Plan (OHIP)
* Interpret with caution due to high sampling variability
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43
EXHIBIT 5B.3 | A
ge-standardized percentage of Ontarians aged 15 and
older with probable depression who had a physician visit for
depression, by sex and rural/urban residency, 2000/01
FINDINGS
•Among rural residents, women with
probable depression were significantly
more likely to have a physician visit for
depression than men (45 percent versus 33
percent, respectively). There were no sex
differences among urban residents.
•Across all LHINs, less than 50 percent of
those with probable depression had a
physician visit for depression within one
year. The rates ranged from 31 percent in
the North East LHIN to 45 percent in the
Central West and Toronto Central LHINs;
however this variation was not significant,
possibly due to small sample sizes at the
LHIN level (data not shown).
Percentage (%)
•The percentage of individuals with
probable depression who had a physician
visit for depression did not vary by rural/
urban residency (data not shown).
100
80
60
45
33
41 37
Rural
Urban
40
20
0
Rural/urban residency
Women
Men
Data sources: Canadian Community Health Survey (CCHS),
Cycle 1.1; Ontario Health Insurance Plan (OHIP); Statistics Canada
2001 Census
Note: See Appendix 5.3 for definitions of rural/urban residency
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44
PERCENTAGE OF OLDER ADULTS STARTING A NEW COURSE OF
ANTIDEPRESSANT MEDICATION WHO RECEIVED ADEQUATE
PHYSICIAN FOLLOW UP
Indicator: This indicator measures the percentage of patients aged 66 and older, who filled and continued a new
prescription for antidepressant medication (i.e., refilled within 100 days) and who had the recommended minimum
of at least three physician visits for depression in the 12 weeks after starting antidepressants.
Background: This indicator assesses the quality of depression care for people on medication. Antidepressants
effectively treat depression in about two-thirds of moderate to severe cases. People vary in their response to both
the kind of antidepressant and the dosage because of factors such as genetic makeup, body mass index, racial
or ethnic background and physical health. Therefore, frequent evaluation by a physician is important during the
first 12 weeks of treatment (the acute phase) to monitor patients’ responses, reduction of symptoms and adverse
reactions to the drug.86 It was not possible to look at all adults who started antidepressant medication, because
prescription data were only available for those aged 65 and older. Because we restricted our sample to people who
had not filled a prescription for antidepressants in the previous year, the sample was limited to people aged 66 and
older to be able to confirm this.
Findings: In Ontario, 9.6 percent of patients aged 66 and older (9.5 percent of women and 9.9 percent of men) who
filled and continued a new prescription for antidepressants had at least three physician visits for depression in the 12
weeks after starting medication.
45
EXHIBIT 5B.4 | A
ge-standardized percentage of adults aged 66 and older, starting
a new course of antidepressants^ who had three or more physician
visits for depression within 12 weeks of starting medication, by sex
and neighbourhood income quintile, in Ontario, 2005/06†
FINDINGS
•Women and men living in lower-income
neighbourhoods were somewhat less
likely to have had at least three physician
visits for depression after starting on
antidepressants than those living in higherincome neighbourhoods. This difference
was not significant among men, possibly
due to small sample size.
Percentage (%)
•There was no difference in the percentage
of women and men aged 66 and
older who had at least three physician
visits for depression after starting
on antidepressants, irrespective of
25
20
15
10
8.7 9.3
9.6 9.1
9.5 10.0
9.7 9.8
Q1
(lowest)
Q2
Q3
Q4
10.7 11.0
5
0
Q5
(highest)
Women
Men
Data sources: Ontario Drug Benefits (ODB) database; Ontario Health
Insurance Plan (OHIP); Statistics Canada 2001 Census
^ People with no history of antidepressant use in the past year, who then
filled two or more antidepressant prescriptions with a 100-day period
†People whose first prescriptions were filled from Mar 1, 2005 Feb 28, 2006
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46
EXHIBIT 5B.5 | P
ercentage of adults aged 66 and older, starting a new course
of antidepressants^ who had three or more physician visits for
depression within 12 weeks of starting medication, by sex and
age group, in Ontario, 2005/06†
FINDINGS
•Women and men were equally
disadvantaged, irrespective of age,
income or LHIN (income and LHIN data
are not shown).
Percentage (%)
•The percentage of patients who had the
recommended number of physician visits
to monitor antidepressant use declined
significantly with age for women and men.
25
15
11.6 12.0
10.4 10.7
10
7.3 7.1
5
0
66-70
71-80
81+
Age group (years)
•This age variation was consistent across most
Local Health Integration Networks (LHINs).
•Older patients often see their physicians for
a complex variety of health problems, so we
broadened this indicator to include physician
visits for any reason, even though the data
did not allow us to assess whether care for
depression was actually provided. The more
broadly defined version of this indicator
showed substantially higher rates for both
sexes, ranging between 80 and 90 percent.
There were no sex differences for this version
of the indicator across age, neighbourhood
income, or LHIN (data not shown).
20
Women
Men
Data sources: Ontario Drug Benefits (ODB) database; Ontario Health
Insurance Plan (OHIP)
^ People with no history of antidepressant use in the past year, who then
filled two or more antidepressant prescriptions within a 100-day period
†People whose first prescriptions were filled from Mar 1, 2005 Feb 28, 2006
•The age variation seen in the broader
definition of follow up was the opposite of
that found for the narrower definition. The
percentage of people who saw their doctors
three times in the 12 weeks after they
started a new course of antidepressants
increased significantly with age, from 80
percent (aged 66-70) to 84 percent (aged
71-80) to 87 percent (aged 81 and older).
•As was the case for the narrower definition,
the age variation was consistent and
significant across most LHINs.
POWER Study
47
In Ontario, 9.6% of individuals, aged 66 and older
who started and continued on an antidepressant had
at least three physician visits for depression in the
12 weeks after starting medication.
H U D S
O
N
H U D S
O
N
B
A
EXHIBIT 5B.6 | Percentage of adults
aged 66 and older, starting a new course
of antidepressants^ who had three or
more physician visits for depression within
12 weeks of starting medication, by Local
Health Integration Network (LHIN), in
Ontario, 2005/06†
Y A
B
Y
FINDINGS
•Unadjusted rates of having had three or more physician visits
for depression after starting and continuing on antidepressant
medication ranged from 5.9 percent in the North West LHIN to
13.6 percent in the Toronto Central LHIN.
•After adjusting for age, these rates remained similar to the
In Ontario, 9.6%
individuals,
aged5.9
66 percent
and olderin the North West
unadjusted
rates,ofranging
from
who
started 9.6%
and continued
on anaged
antidepressant
had
In
Ontario,
of
individuals,
66
and older
LHIN
to 13.5
percent invisits
thefor
Toronto
Central
LHIN. Furthermore,
atwho
leaststarted
three physician
depression
in the had
and continued on
an
antidepressant
the12pattern
across
LHINs
did not change (data not shown).
weeks after
starting
medication.
L A K E
N I P I G O N
L A K E
N I P I G O N
K E
L A
at least three physician visits for depression in the
12 weeks after starting medication.
R
S U P E R
I O
K E
L A
•For the broader definition of physician follow up, unadjusted
rates ranged from 76 percent in the North West LHIN to 88
percent in the Central LHIN (data not shown).
POWER Study
S U P E R
I O
R
E
Local Health Integration Networks (LHINs)
1 Erie St. Clair
4 Hamilton
Niagara
Haldimand Brant
2 South West
L
A
5 Central West
3 Waterloo
K Wellington
6 Mississauga Halton
7 Toronto Central
8 Central
9
10
11
12
H
U
13
N
R O
14
Central East
South East
Champlain
North
Simcoe
Muskoka
North East
North West
K E
L A
O
† People wh
L
L
E
A
K
L
A
E
A K
E R I E
K
H
E
RNO
RUO
UH
N T A R I O
K E O
L A
N T A R I O
O
E
K
L A
N
† People whose first prescriptions were filled from Mar 1, 2005 - Feb 28, 2006
L
48
E
A K
E
A K
L
E R I E
E R I E
Peoplewith
whose
first prescriptions
were filled
2005who
- Feb
28,filled
2006two
^ †People
no history
of antidepressant
use from
in theMar
past1,year,
then
or more antidepressant prescriptions with a 100-day period
^ People with no history of antidepressant use in the past year, who then filled two
or more antidepressant prescriptions with a 100-day period
Data sources: Ontario Drug Benefit Claims (ODB) database; Ontario Health
Insurance Plan (OHIP)
^ People wi
or more ant
Percentage of women who had a physician visit for depression
within one year of giving birth
Indicator: This indicator measures the percentage of Ontario women who had a physician visit for depression
within one year of giving birth in a hospital (excluding still births).
Background: Postpartum depression is estimated to occur after 13 percent of births87 although the rate varies
across countries and ethnic groups.88, 89 Its impact on the mother, child and family can be substantial, both in the
short- and long-term. This indicator provides baseline descriptive information on the proportion of Ontario women
who had a physician visit for depression within one year of giving birth.
Findings: In Ontario, 20 percent of women who had given birth saw a physician for depression within one year
of delivery.
EXHIBIT 5B.7 | A
ge-standardized percentage of women who had a physician visit for
depression within one year of giving birth, by neighbourhood income
quintile, in Ontario, 2005/06^
FINDINGS
•This indicator varied significantly by age;
20 percent of women aged 25-44 had a
physician visit for depression within a year
of giving birth compared to 24 percent
of women aged 15-24. The rate in the
oldest age group (aged 45-64) was less
reliable because of small numbers (data
not shown).
•There was significant regional variation in
the percentage of women who gave birth
and had a subsequent physician visit for
depression within a year, ranging from
15 percent in the North West LHIN to 26
percent in the North Simcoe Muskoka
LHIN (data not shown).
Percentage (%)
•The percentage of women who gave
birth and then had a physician visit for
depression within one year did not vary by
50
40
30
20
21
21
20
20
21
Q1
(lowest)
Q2
Q3
Q4
Q5
(highest)
10
0
Data sources: ICES Mother-Baby (MOMBABY) Linked Database;
Ontario Health Insurance Plan (OHIP); Statistics Canada 2001 Census
^ Women with in-hospital live births (stillbirths were excluded) who were
discharged between Mar 1, 2005 - Feb 28, 2006
note: See Appendix 5.3 for details about neighbourhood income
POWER Study
49
Section 5B
Summary of FIndings
The indicators in this section include three measures
with probable depression were the most likely to visit
of depression care provided in primary or specialty
a physician for depression, although they were not the
outpatient settings:
age group with the highest prevalence. Among older
Ontarians starting antidepressants, age was associated
• Care for Ontarians with probable depression;
with a decreasing likelihood of physician visits for
• Care for older Ontarians starting a new course of
depression but an increasing likelihood of physician
antidepressant medication and
visits for any reason.
• Care for postpartum women.
Finally, there were differences by income. Women with
The first two indicators shared several patterns. We
probable depression who had lower annual household
found women and men faced no significant differences
incomes were more likely have a physician visit for
in their access to care. Forty-one percent of women and
depression than those with higher annual household
37 percent of men with probable depression had at
incomes. However, older women from lower-income
least one physician visit for depression within a year of
neighbourhoods who started antidepressants were less
their survey interview. Older Ontarians who started an-
likely to have had the recommended number of follow
tidepressant medications had the lowest follow up rates
up physician visits than women from higher-income
for depression (i.e., at least three physician visits for
neighbourhoods.
depression within 12 weeks of starting medication); 9.5
The third indicator measured depression care for
percent of women and 9.9 percent of men, although
postpartum women. The finding that 20 percent of
roughly 85 percent had at least three physician visits for
Ontario women who gave birth had a physician visit
any reason in the important first 12 weeks after starting
for depression in the year after delivery was consider-
antidepressants. Better data are needed to more
ably higher than the rate of postpartum depression
accurately assess depression care in outpatient settings.
reported in the literature (13 percent).87 One possible
We showed potential under-treatment for depression—
explanation is the large number of immigrants in
60 percent of Ontarians with probable depression did
Ontario. Stewart and colleagues25 found that 35
not have a physician visit for depression care. Because
percent of women in Ontario and Quebec who had
there is a high potential for impairment of functioning
immigrated to Canada less than five years ago scored
associated with depression, but a good record of effec-
10 or higher on the Edinburgh Postnatal Depression
tiveness for both drug and non-drug therapies, many of
Scale, which is the usual cut off score for probable
those who do not get care may be suffering needlessly.
depression in community samples.88 It is also possible
Further, monitoring patients’ responses to drugs and
that physicians and some groups of new mothers are
their side effects is a critical component of high-quality
more aware of the possibility of postpartum depression,
care in general, especially for fragile populations such as
or that the numbers differed because of the way
older adults.
physicians use OHIP codes to bill for counselling non-
All the indicators showed disparities associated with age
although the patterns differed. Ontarians aged 45-64
50
depressed women in some Local Health Integration
Networks (LHINs).
The limitations in our data mean we cannot be
depression. The significant differences in postpartum
certain why our findings of the rates of physician
physician visits for depression across the LHINs (ranging
visits for depression during the postpartum period
from 15 to 26 percent) suggest local practice patterns
were different from other studies. However, because
or the way services are organized regionally may
there were no significant differences by neighbour-
influence rates of physician visits for depression. Other
hood income, and younger women were more likely
factors that predict postpartum depression, such as
than those aged 25-44 to have physician visits for
social support or poor marital relationships, may also
postpartum depression, it suggests need, as measured
play a role87 and could be explored if data on those
by prevalence, is not fully reflected in physician visits for
issues become available in Ontario.
51
Section 5C
Acute and Specialty Inpatient Care
Prevention/
health
promotion
Community
services/
supports
Primary
care
Specialty
outpatient
care
Acute
hospital
care
Specialty
hospital
care
Introduction
Acute and specialty hospital care are also vital components of
the continuum of depression care. Important services for those
with severe depression are provided by emergency departments,
inpatient units of acute care hospitals or psychiatric hospitals.
The aim of these services is to ameliorate severe
It is also important to look at indicators of inpatient care
depression symptoms, prevent mortality due to depression
because they serve people with the most complex and
and stabilize the individual so that she or he can benefit
serious forms of depression. These acutely ill patients may
from outpatient and other community-based care.
be very fragile and at risk of imminent harm to themselves
(either due to suicidal intentions or because they are
The percentage of people who visit emergency
unable to look after their own basic needs) or to others.
departments or are hospitalized for depression is
quite small: only about 1.5 percent of Ontario’s adult
population had emergency department visits for mental
Depression of this severity is associated with the highest
individual, family and societal burden.95
health reasons.90 Hospitalization rates specifically for
The Canadian clinical treatment guidelines for depressive
depression are also low, at only 80-150 per 100,000
disorders recommend that discharge from hospital
91
for women and 60-100 per 100,000 for men.
services include a discharge plan that refers the patient to
Nevertheless, it is important for us to look closely
relevant mental health services and monitoring since the
at acute and specialty hospital care because these
period after discharge is high-risk for suicidal behaviour.96
services are quite resource intensive. Although Ontario
has focused on reducing the rate of hospitalization
for major depression,65, 92, 93 it still accounted for 18
percent ($80 million) of the province’s total direct health
care costs for major depression in 2000.94
52
Research has found gender differences in hospital care
for other health conditions, including heart attacks.97
We know women have a higher rate of hospitalization
for depression.98 However, sex differences in the
management and outcomes of acute and specialty
Depression | Section 5C
inpatient care for depression have not been previously
reported for Ontario. This information is important for
assessing whether there are gender inequities in the
depression care delivered here.
In this section we assess sex differences in patterns of
acute and specialty inpatient care for depression. The
evidence-based indicators for measuring process and
outcomes in acute and speciality inpatient services
were measured in patients admitted to hospital for
depression and include:
• Physician visits for depression within 30 days of
discharge;
• Average number of days post-discharge to first
physician visit for depression;
• Emergency department visits (with no subsequent
hospital admission) within 30 days of discharge;
• 30-day readmission rate for depression.
These indicators are based on data from all Ontario
hospitals submitting discharge records to the Canadian
Institute for Health Information Discharge Abstracts
Database (CIHI-DAD) which, at the time of writing,
did not include four psychiatric or former psychiatric
hospitals. However, because the vast majority of
hospitalizations for depression are in general hospitals
(all covered in the CIHI-DAD) and people admitted
to the four speciality hospitals tend to stay longer
and are less likely to be discharged within a year, the
proportion of discharges for depression that could
be missed should be quite small. The accuracy of the
CIHI-DAD information on hospital stays for depression is
considered quite high because of the precise diagnostic
codes used.
The first two indicators in this section measure physician
visits for depression following hospitalization for
depression. As noted in Section 5B, the definition of a
physician visit for depression in this chapter is imprecise
and may either under- or over-estimate the number of
physician visits for depression care due to limitations of
Ontario Health Insurance Plan (OHIP) codes for these
visits (see Appendix 5.3 for more detail).
53
Physician visits for depression within 30 days of
hospital discharge
Indicator: This indicator measures the percentage of patients aged 15 and older hospitalized for depression who
had a physician visit for depression within 30 days of discharge.
Background: Post-discharge follow up care, including ongoing medical attention, is critical for people experiencing severe depression. Recent work in Ontario found that 80 to 90 percent of clients in community mental health
programs or provincial hospitals are on psychotropic medication and that compliance and symptom and medication
management are important concerns for these individuals.99
Findings: In Ontario, 63 percent of patients (65 percent of women and 60 percent of men) who were hospitalized
for depression had a follow up physician visit for depression within 30 days of discharge.
EXHIBIT 5C.1 | A
ge-standardized percentage of patients aged 15 and older
admitted to hospital for depression who had a physician visit for
depression within 30 days of discharge, by sex and neighbourhood
income quintile, in Ontario, 2005/06^
FINDINGS
•Regardless of income, men were less likely
than women to receive physician follow
up after a hospital stay for depression.
•Income was a significant factor in
who received physician care following
hospitalization for depression. Women
and men living in lower-income
neighbourhoods had lower rates of
physician follow up than those from
higher-income neighbourhoods.
•Sex differences in physician follow up care
persisted across age groups (data
not shown).
Percentage (%)
•One in three Ontario women and men
did not have a physician visit within 30
days of being discharged after a hospital
100
80
60
62
56
64
59
65 61
68
63
70
64
40
20
0
Q1
(lowest)
Q2
Q3
Q4
Q5
(highest)
Women
Men
Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP);
POWER Study
54
EXHIBIT 5C.2 | A
depression within 30 days of discharge, by sex and rural/urban
residency, in Ontario, 2005/06^
FINDINGS
•Urban residents who were hospitalized for
depression were significantly more likely
than rural residents to have a physician
visit for depression within 30 days of
hospital discharge (64 percent versus 59
percent) (data not shown).
Percentage (%)
•A larger percentage of women than men
had a physician visit for depression within
30 days of discharge, irrespective of rural/
urban residency.
100
80
60
62
66
55
61
40
20
0
Rural
Urban
Rural/urban residency
Women
Men
Note: See Appendix 5.3 for definitions of rural/urban residency
POWER Study
55
14
51%
Overall Ontario
In Ontario, 63% of all inpatient stays for depression
were followed by one or more physician visits for
depression within 30 days after discharge.
Northern
Ontario
Northern
Ontario
63%
0
H U D S
O
N
H U D S
O
B
N
Y A
B
Y
FINDINGS
13
•The unadjusted rates of physician visits for depression
within 30 days of discharge varied significantly by LHIN.
The rates were lowest in the South East LHIN (50 percent)
and highest in the Central LHIN (72 percent).
Overall Ontario
Ontario
InOverall
Ontario, 63%
of all inpatient stays for depression
In Ontario, 63% of all inpatient stays for depression
59%
13
14
59%
51%
14
51%
L A K E
N I P I G O N
13
L A K E
N I P I G O N
Thunder Bay
63%
Thunder Bay
K E
L A
63%
0
250
0
POWER Study
59%
S U P E R
I O
R
S U P E R
I O
K E
L A
Sudbury
R
Sudbury
500 Km
250
500 Km
H
U
N
R O
59%
9
10
6
68%
13
59%
Hamilton
4
11
61%
64%
11 London
64%
1
Ottawa
9
57%
12
65%
9
57%
Windsor
65%
^ People wh
Ottawa
64%
12
10
50%
10L A
K E
E R I E
50%
Kingston
Barrie
H
E
RNO
R UO
UH
2
2
59%
N
1
56
61%
Hamilton
N T A R I O
K E O
L A
N T A R I O
O
E
K
L A
Southern
Ontario
Southern
Ontario
50
0
0
50
100 Km
100 Km
less than 60
60 to 65
less than 60
greater than 65
60 to 65
greater than 65
^ People who were discharged from hospital from Mar 1, 2005 - Feb 28, 2006
64%
Windsor
69%
6
4
1
7 Toronto
Hamilton 68%
61%
London
64%
Windsor
6
4
London
69%
Mississauga
68%
Kitchener
Markham
7 Toronto
Mississauga
Kitchener
Markham
8
72%
Orangeville
Kingston
Peterborough
72%
65%
Orangeville
3
65%
59%
8
5
65%
K
Peterborough
Barrie
65%
3
E
A
K
L
A
5
L
E
A K
E
A K
L
E R I E
E R I E
9
65%
Central
East
Barrie
Peterborough
South
East
5
11
8
65% Champlain
72%
Markham
12 North
Simcoe
Orangeville
Muskoka
13 North East
K E O
7 Toronto
L A
Kitchener 14 Mississauga
North West 69%
E
13
59%
12
57%
1 Erie St. Clair
4 Hamilton
Niagara
Haldimand Brant
2 South West
L
A
5 Central West
3 Waterloo
K Wellington
3
65%
7 Toronto Central
2
8 Central
L
250
A
EXHIBIT 5C.3 | Percentage of
patients aged 15 and older admitted
to hospital for depression who had
a physician visit for depression within
30 days of discharge, by Local Health
Integration Network (LHIN), in
Ontario, 2005/06^
Data sources: Canadian Institute for Health Information Discharge Abstract
Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP)
EXHIBIT 5C.4 | A
depression within 30 days of discharge, by sex and Local Health
Integration Network (LHIN), in Ontario, 2005/06^
Percentage (%)
100
80
65 64
60
62
68
56
62
62 59
66
72
62
71
62
67
74
70
67
68
63
53
57
62
60
51
45
56
50 52
40
20
0
1
2
3
Women
4
5
6
7
8
9
10
11
12
13
14
Men
1. Erie St. Clair
11. Champlain
2. South West
7. Toronto Central
8. Central
13. North East
9. Central East
14. North West
5. Central West
10. South East
Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD);
Ontario Health Insurance Plan (OHIP)
FINDINGS
•The age-standardized rates of physician visits for depression within 30 days of discharge from hospital
were higher among women than men in most LHINs.
•The age-standardized rates of physician visits within 30 days showed significant regional variation for
both sexes. Among women, rates ranged from 50 percent in the North West LHIN to 74 percent in the
Central LHIN; among men, rates ranged from 45 percent in the South East LHIN to 70 percent in the
Central LHIN.
POWER Study
57
Time from hospital discharge to first physician visit
for depression
Indicators: Two indicators measure the time from discharge to the first physician visit for depression among patients
hospitalized for depression. The first is the percentage of discharged patients aged 15 and older who had a physician
visit for depression within 30 days (see also the previous indicator), 30 days to 12 weeks, 12 weeks to six months and
six to 12 months, as well as those who did not see a physician for depression in the year after discharge. The second
is the mean number of days to the first physician visit for those who were seen by a physician within one year of
discharge from hospital.
Background: The first visit is used as a proxy for the promptness of adequate follow up. Prompt follow up after
discharge may help prevent unnecessary readmission to hospital.
Findings: In Ontario, 10 percent of women and 14 percent of men aged 15 and older were not seen by a physician
within one year of hospital discharge. People who had been hospitalized for depression and who were seen within 30
days of discharge, had an average of 9.6 days for women and 9.7 days for men to their first physician visit for depression.
Over the course of one year, the average time to a physician visit was 37 days for women and 41 days for men.
EXHIBIT 5C.5 | P
ercentage of patients aged 15 and older admitted to hospital
for depression who had a post-discharge physician visit
for depression, by sex and time from discharge, 2005/06^
FINDINGS
•The gender gap did not narrow over time:
10 percent of women and 14 percent of
men had no physician visit for depression
in the 12 months after they were
discharged from hospital.
•The time between discharge and a first
physician visit for depression, among
people seen within the first 30 days, did
not differ by sex (9.6 days for women and
9.7 days for men), but it did differ for
people who were seen over the course of
a year (data not shown).
Percentage (%)
•Less than two-thirds of women (65
percent) and men (60 percent) had a
physician visit for depression within 30
days of hospital discharge. Women were
somewhat more likely than men to have
had a visit within this period.
100
80
60
65
60
40
20
0
14 14
<30 days
>30 days to
12 weeks
7 7
5 5
>12 weeks to
6 months
>6 months to
12 months
10
14
No visit within
12 months
Time from discharge
Women
Men
Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP)
POWER Study
58
FINDINGS
•Following a hospitalization for
depression, people living in lower-income
neighbourhoods had a longer time to a
physician visit for depression than those
from higher-income neighbourhoods (43
days versus 34 days, respectively) (data
not shown).
Number of days (mean)
EXHIBIT 5C.6 | M
ean number of days to a first physician visit¥ for depression in
patients aged 15 and older admitted to hospital for depression,
by sex and neighbourhood income quintile, in Ontario, 2005/06^
50
43
38
37 37
38
33
38
32
30
20
10
0
•The mean number of days to the first
physician visit for depression varied
significantly by income for women
and men.
43 43
40
Q1
(lowest)
Q2
Q3
Q4
Q5
(highest)
Women
Men
¥For patients who were seen by a physician within 12 months
of discharge
POWER Study
59
FINDINGS
•Across all age groups, the mean number
of days between discharge to the first
physician visit for depression was longer
for men than women.
•On average, those aged 15-24 had a
significantly longer time to a physician
visit for depression than other age groups.
The mean number of days to the first visit
were similar in the other age groups.
Number of days (mean)
EXHIBIT 5C.7 | M
ean number of days to a first physician visit¥ for depression in
patients aged 15 and older admitted to hospital for depression,
by sex and age group, in Ontario, 2005/06^
50
40
46
41
40
36
37
39
37
39
30
20
10
0
15-24
25-44
45-64
65+
Age group (years)
Women
Men
Abstract Database (CIHI-DAD); Ontario Health Insurance Plan (OHIP)
¥For patients who were seen by a physician within 12 months
of discharge
POWER Study
60
30-day post-discharge rate of emergency department (ED)
visits (with no subsequent hospital admission)
Indicator: This indicator measures the percentage of Ontarians aged 15 and older who were hospitalized for
depression who had an emergency department (ED) visit (but were not readmitted) within 30 days of
being discharged.
Background: A high percentage of patients visiting an ED shortly after their discharge from an inpatient stay for
depression may signal less-than-optimal continuity of care.58 A high rate may reflect poor discharge planning, a
lack of appropriate community supports or poor integration with community services.
Findings: In Ontario, 17 percent of patients aged 15 and older (17 percent of women and 18 percent of men) who had
been in hospital for depression were seen in an ED within 30 days of discharge, but were not readmitted at that time.
EXHIBIT 5C.8 | A
hospitalized for depression who were seen in an emergency
department (ED) within 30 days of discharge without a subsequent
hospitalization, by sex and neighbourhood income quintile, in
Ontario, 2005/06^
FINDINGS
Percentage (%)
•There was significant income variation
in the percentage of men who had an
ED visit within 30 days of discharge from
hospital; 22 percent of men from lowerincome neighbourhoods were seen in an
ED compared to 13 percent of men from
higher-income neighbourhoods. The
income difference among women
was smaller.
50
40
30
20
19
22
16
18
15
18
15 16
17
13
10
0
Q1
(lowest)
Q2
Q3
Q4
Q5
(highest)
Women
Men
Abstract Database (CIHI-DAD); National Ambulatory Care Reporting
System (NACRS); Statistics Canada 2001 Census
POWER Study
61
EXHIBIT 5C.9 | P
ercentage of patients aged 15 and older hospitalized for
depression who were seen in an emergency department (ED)
within 30 days of discharge without a subsequent hospitalization,
by sex and age group, in Ontario, 2005/06^
FINDINGS
•In the youngest age group, 19 percent of
women versus 14 percent of men were seen
in an ED in the 30 days following a hospital
stay for depression. This pattern was
reversed among those aged 45-64, with 15
percent of women and 19 percent of men
being seen in an ED within 30 days.
•ED visits within 30 days of hospital
discharge were more common among
rural residents than urban residents (21
percent versus 16 percent, respectively)
(data not shown).
Percentage (%)
•Ontarians aged 65 and older were less likely
to be seen in an ED in the 30 days following
a hospital stay for depression. The rate in
this age group was 13 percent, compared
to a combined rate of 18 percent for those
under age 65 (data not shown).
50
40
30
20
19 20
19
14
15
19
13 14
10
0
15-24
25-44
45-64
65+
Age group (years)
Women
Men
Abstract Database (CIHI-DAD); National Ambulatory Care Reporting
System (NACRS)
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62
14
19%
Overall Ontario
In Ontario, 17% of patients with depression
had ED visits without a resulting hospitalization
within 30 days of discharge from hospital.
Northern
Ontario
Northern
Ontario
17%
0
H U D S
O
N
H U D S
O
250
B
N
A
EXHIBIT 5C.10 | Percentage of
patients aged 15 and older hospitalized
for depression who were seen in an
emergency department (ED) within 30
days of discharge without a subsequent
hospitalization, by Local Health Integration
Network (LHIN), in Ontario, 2005/06^
Y A
B
Y
FINDINGS
13
21%
•There was significant regional variation in the percentage
of people who visited an ED within 30 days of discharge
after a hospital stay for depression. The unadjusted rates
ranged from 11 percent in the Central West LHIN to 21
Overall Ontario
percent in the South West, South East and North East
InOverall
Ontario, Ontario
17% of patients with depression
LHINs.
In Ontario, 17% of patients with depression
13
14
21%
19%
14
19%
L A K E
N I P I G O N
13
L A K E
N I P I G O N
Thunder Bay
17%
Thunder Bay
S U P E R
I O
K E
L A
17%
R
S U P E R
I O
K E
L A
0
250
0
21%
Sudbury
R
Sudbury
500 Km
250
12
9
15%
18%
500 Km
POWER Study
1 Erie St. Clair
4 Hamilton
Niagara
Haldimand Brant
2 South West
L
A
5 Central West
3 Waterloo
K Wellington
3
14%
7 Toronto Central
2
8 Central
21%
E
Central
East
Barrie
Peterborough
South East
8
11 Champlain
11%
15%
12 North
Simcoe Markham
Orangeville
Muskoka
13 North East 7 Toronto
K E O
L A
Kitchener 14Mississauga
19%
North West
6
H
U
N
R O
13
21%
9
510
14%
13
21%
Hamilton
4
11
16%
18%
11 London
Ottawa
18%
1
9
15%
12
18%
9
15%
Windsor
18%
^ People who
Ottawa
13%
12
10
21%
A
10
L
K E
E R I E
21%
Kingston
Barrie
L
H
E
N
RNO
R UO
UH
2
2
21%
1
6
6
Hamilton 14%
16%
4
Hamilton
16%
London
13%
1
Windsor
7 Toronto
19%
N T A R I O
K E O
L A
N T A R I O
O
E
K
L A
Southern
Ontario
Southern
Ontario
0
0
50
50
100 Km
100 Km
less than 15
15 to 18
less than 15
19 and higher
15 to 18
19 and higher
13%
Windsor
19%
Mississauga
14%
4
Markham
7 Toronto
Mississauga
Kitchener
London
15%
Orangeville
Kitchener
Markham
8
11%
Orangeville
3
Kingston
Peterborough
15%
14%
21%
8
5
14%
K
Peterborough
Barrie
11%
3
E
A
K
L
A
5
L
E
A K
E
A K
L
E R I E
E R I E
Database (CIHI-DAD); National Ambulatory Care Reporting System (NACRS)
63
EXHIBIT 5C.11 | A
hospitalized for depression who were seen in an emergency
department (ED) within 30 days of discharge without a
subsequent hospitalization, by sex and Local Health Integration
Percentage (%)
50
40
30
25
21 21
20
12
14
14 14
15 16
3
4
10
10
0
1
2
Women
14
5
20
16
17
11
6
7
15 14
8
17
20
9
17
10
19
17
11
25
21 22
15 15
12
13
13
14
Men
1. Erie St. Clair
11. Champlain
2. South West
7. Toronto Central
8. Central
13. North East
9. Central East
14. North West
5. Central West
10. South East
Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD); National
Ambulatory Care Reporting System (NACRS)
FINDINGS
•There was significant regional variation in the age-standardized rates of ED visits within 30 days of
discharge after a hospital stay for depression. Among women, the rates ranged from 10 percent in
the Central West LHIN to 21 percent in the South West and North East LHINs. Among men, the rates
ranged from 11 percent in the Mississauga Halton LHIN to 25 percent in the South East and North
West LHINs.
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64
30-day readmission rate for depression
Indicator: This indicator measures the percentage of patients aged 15 and older who were readmitted to hospital
for depression in the 30 days post-discharge after a hospital stay for depression.
Background: The role of inpatient care in mental health is to stabilize individuals experiencing acute episodes of
illness so they can be discharged to community-based services and supports. Readmission to hospital shortly after
a previous inpatient stay suggests problems in the continuity of care. It may indicate inadequate preparation for
discharge, poor community-based follow up or a lack of adequate community services. For this indicator, readmissions
can be to the same or a different hospital, but transfers between hospitals are not considered readmissions. Since
this may be an access issue, rates may vary by geographic location, sex, or other population subgroups.
Finding: In Ontario, 7.6 percent of both women and men aged 15 and older who had been hospitalized for
depression were readmitted to hospital for depression within 30 days of discharge.
EXHIBIT 5C.12 | A
ge-standardized 30-day readmission rate (percentage) for depression
among patients aged 15 and older admitted to hospital for depression,
by sex and neighbourhood income quintile, in Ontario, 2005/06^
FINDINGS
•Readmission rates for depression did not
vary by age group or rural/urban residency
(data not shown).
Percentage (%)
•Readmission rates did not vary by income
for women or men.
25
20
15
10
8.0 7.2
7.4
9.0
6.7 6.5
7.5 7.1
8.2 8.0
Q3
Q4
Q5
(highest)
5
0
Q1
(lowest)
Q2
Women
Men
Abstract Database (CIHI-DAD); Statistics Canada 2001 Census
note: See Appendix 5.3 for details about neighbourhood income
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65
14
9.2%
Overall Ontario
EXHIBIT 5C.13 | 30-day readmission
rate (percentage) for depression among
patients aged 15 and older admitted
to hospital for depression, by Local
Health Integration Network (LHIN), in
Ontario, 2005/06^
In Ontario, 7.6% of all inpatient stays for depression
were followed by readmission within 30 days after
discharge.
Northern
Ontario
Northern
Ontario
7.6%
0
H U D S
O
N
H U D S
O
B
A
N
250
Y A
B
Y
FINDINGS
13
•Unadjusted readmission rates for depression showed significant
regional variation.
11.9%
11.9%
14
•Readmission rates ranged from 2.9 percent in the Erie St. Clair
LHIN to 11.9 percent in the North East LHIN.
Overall Ontario
InOverall
Ontario, Ontario
7.6% of all inpatient stays for depression
were
followed
by readmission
within
30for
days
after
In Ontario,
7.6%
of all inpatient
stays
depression
discharge.
were followed by readmission within 30 days after
13
14
9.2%
9.2%
L A K E
N I P I G O N
L A K E
N I P I G O N
13
11.9%
Thunder Bay
7.6%
discharge.
Thunder Bay
S U P E R
I O
K E
L A
7.6%
R
S U P E R
I O
K E
L A
0
250
0
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Sudbury
R
Sudbury
500 Km
250
500 Km
1 Erie St. Clair
4 Hamilton
Niagara
Haldimand Brant
2 South West
L
A
5 Central West
3 Waterloo
K Wellington
3
8.4%
7 Toronto Central
2
8 Central
H
U
N
R O
7.9%
9
10
8.9%
13
11.9%
Hamilton
4
11
7.2%
7.4%
11 London
Ottawa
7.4%
1
9
3.6%
12
7.0%
9
3.6%
Windsor
7.0%
^ People wh
Ottawa
2.9%
12
10
5.1%
10L A
K E
E R I E
5.1%
Kingston
Barrie
L
H
E
RNO
RUO
UH
2
7.9%
2
7.9%
Kitchener
4
Hamilton
N T A R I O
K E O
L A
N T A R I O
O
E
K
L A
Southern
Ontario
Southern
Ontario
0
0
50
50
100 Km
100 Km
less than 6.0
6.0 to 8.0
less than 6.0
greater than 8.0
6.0 to 8.0
greater than 8.0
2.9%
66
6
7.2%
London
Markham
7 Toronto
Hamilton 8.9%
7.2%
1
Markham
10.1%
6
7 Toronto
Mississauga
8.9% 10.1%
Kitchener
N
1
8
6.3%
Mississauga
Kingston
Peterborough
6.3%
Orangeville
4
2.9%
Windsor
5.2%
Orangeville
3
8.4%
London
Windsor
8
5
8.4%
K
Peterborough
Barrie
5.2%
3
E
A
K
L
A
5
L
E
A K
E
A K
L
E R I E
E R I E
9
7.0%
Central
East
Barrie
Peterborough
South
East
5
8
11 Champlain
5.2%
6.3%
Markham
12 North
Simcoe
Orangeville
Muskoka
13 North East
K E O
7 Toronto
L A
Kitchener 14Mississauga
10.1%
North West
6
E
13
11.9%
12
3.6%
Database (CIHI-DAD)
EXHIBIT 5C.14 | A
ge-standardized 30-day readmission rate (percentage)
for depression among patients aged 15 and older admitted to
hospital for depression, by sex and Local Health Integration
Percentage (%)
25
20
15
9.4
10
5
0
6.8
9.0
7.5
7.2 7.2
9.4
5.5
3.2 2.6
1
2
Women
3
4
7.9
9.7
5.8
4.5
5
6
12.1 11.4
10.7
7
7.3
6.9 7.2
8
9
8.3
8.2
4.6 5.4
10
5.9
11
4.5
10.1
2.3
12
13
14
Men
1. Erie St. Clair
11. Champlain
2. South West
7. Toronto Central
8. Central
13. North East
9. Central East
14. North West
5. Central West
10. South East
Data sources: Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD)
FINDINGS
•Age-standardized readmission rates for depression varied significantly across LHINs for both sexes. The
rates for women ranged from 3.2 percent (Erie St. Clair LHIN) to 12.1 percent (North East LHIN). For
men, the rates ranged from 2.3 percent (North Simcoe Muskoka LHIN) to 11.4 percent (North East LHIN).
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67
Section 5C
Summary of FIndings
The indicators of acute and specialty inpatient services all
post-discharge physician visit for depression within 30
focus on the care a person who has been hospitalized for
days than those living in lower-income neighbourhoods
depression receives post-discharge. While the quality and
or rural areas. The largest differences, however, were
outcomes of the care delivered in hospital are important,
across LHINs, where the rates ranged from 50 percent
the primary purpose is to stabilize depressed patients
to 72 percent.
to the point that they can benefit from less structured
Women and men were equally likely to receive care in
and less intensive community or outpatient services.
an emergency department after being discharged (17
The assumption is that a poor transition from hospital
percent and 18 percent, respectively). Men living in the
to community care will undo the gains the individual
lowest-income neighbourhoods were more likely to visit
made in hospital and also will undermine the value of
keeping people in the community and providing the least
restrictive care possible.65 Higher rates of physician visits
for depression after a hospital stay and lower rates of
emergency department visits or hospital readmissions are
therefore desirable.
an emergency department than men from the highestincome neighbourhoods and men from rural areas were
more likely to return to an emergency department than
those from urban areas. Sex disparities occurred within
age groups; women aged 15-24 had a higher rate of
emergency department visits than men that age, but
Overall, one in three Ontarians did not see a physician
for depression after a hospital stay for depression,
men aged 45-64 had higher rates of use than women.
As was the case for physician care for depression, the
indicating suboptimal care coordination in transition
largest differences were across LHINs. The highest
from the hospital to the community. Women were
rate (21 percent) was almost double the lowest rate
consistently more likely than men to have seen a
physician for depression after discharge from hospital.
(11 percent).
This pattern held true across neighbourhood income
Men and women were equally likely to be readmitted
levels, rural/urban residency and almost all LHINs. The
to hospital for depression within 30 days post-discharge
difference was apparent in the first 30 days after hos-
(7.6 percent for each). There were few differences in
pitalization (65 percent of women versus 60 percent of
readmission rates across age groups, neighbourhood
men) and had not gone away even after a year post-dis-
income levels and rural/urban residency. There were
charge, by which time 90 percent of women had seen
differences across LHINs, however, where rates ranged
a physician for depression versus 86 percent of men.
from 2.9 percent to 11.9 percent. It is often argued that
There was no difference by sex in how long women
high readmission rates may result from hospital stays
and men took to get a follow up visit within the first 30
that are too short but the literature shows the relation-
days of discharge. Beyond 30 days, men had somewhat
ship is not that straightforward and high readmission
longer times to a physician visit.
rates occur in situations with both shorter and longer
lengths of stay.100
People living in higher-income neighbourhoods and
those living in urban areas were more likely to have a
68
Depression | Depression
Section 5C
69
Chapter Summary of Findings
In this chapter, we presented background information
There were also gender and sociodemographic
on the need, use and supply of depression care in
differences in which service sectors were used. Women
Ontario, as well as indicators of inpatient and outpatient
and men living in lower-income neighbourhoods were
depression care. Figure 5 provides a summary of where
almost twice as likely to be hospitalized for depression
sex, income, age and regional differences were found.
but incurred slightly lower average costs for OHIP core
mental health services compared to Ontarians living in
Overall, we found many instances where depression
the highest-income neighbourhoods. Rural residents
care was suboptimal for everyone. Less than half
were more likely to be hospitalized for depression while
of women and men with probable depression (as
urban dwellers accounted for proportionately greater
reported in a national survey) had a physician visit
for this condition within one year. Many older adults
OHIP costs for mental health care.
who started on antidepressant therapy did not receive
A comparison of need, use and supply across Local
the recommended number of follow up visits for
Health Integration Networks (LHINs) suggested that the
medication management. One in three women and
geographic patterns of use reflected the geographic
men hospitalized for depression did not have a follow
distribution of supply more than need.
up physician visit for depression within 30 days of
hospital discharge and nearly one in five patients had
an emergency department visit in this time frame,
We reported results for several indicators of depression
care. For some indicators, we found no significant
sex differences. Women and men with probable
indicating suboptimal care coordination during
depression had similar rates of having a physician visit
care transitions.
for depression within a one-year period. Men and
We found differences in the prevalence of depression—
women aged 66 and older who started on a new
one of the important markers of need for depression
course of antidepressants were equally likely to have
care—across sex, age, income and geography. We
had the recommended number of physician follow up
also found differences in the use of services for both
visits. And women and men who were hospitalized for
depression and mental health in general. In some cases,
depression were equally likely to be readmitted or to
the prevalence patterns were similar to the service use
have visited an emergency department in the month
patterns. For example, women had higher rates of
after they were discharged.
both depression and use of Ontario Health Insurance
Plan (OHIP) core mental health services. In other cases,
however, the patterns differed. For example, lowerdepression but had the same rate of use of OHIP core
70
who were hospitalized for depression, women were
more likely than men to have had a physician visit for
income women were more likely to report probable
mental health services as higher-income women.
There were some gender differences. Among people
depression within 30 days of discharge. For those who
were seen by a physician within 30 days of discharge,
there was no difference in the mean time women and
Depression | Summary of Findings
men took to have their first physician follow up visit.
do so more quickly) than those from lower-income
Beyond 30 days, men took somewhat longer to see
neighbourhoods. And, men living in the lowest-income
a physician.
neighbourhoods were more likely than men from the
A few indicators of depression care were associated
with age. Ontarians with probable depression aged
45-64 were the most likely to have had a physician visit
highest-income neighbourhoods to visit the emergency
department in the one month period post-discharge
after a hospital stay for depression.
for depression, although they were not the group with
Some rural/urban differences were seen. People living in
the highest prevalence. Among older Ontarians starting
urban areas were more likely to have a post-discharge
antidepressants, age was associated with a decreasing
physician visit for depression than people living in rural
likelihood of adequate follow up (i.e., three or more
areas. Also, men from rural areas were more likely to
within the 12 weeks after starting medication) for
visit an emergency department after discharge than
depression but an increasing likelihood of having had
those from urban areas.
three or more physician visits for any reason.
Variations across Local Health Integration Networks
Disparities by income were found in several indicators.
(LHINs) were seen for a number of indicators, and
Among women with probable depression, those who
these represented the largest disparities reported in this
had lower household incomes were more likely to
chapter. Differences between the highest and lowest
see a physician for depression than those with higher
LHINs ranged from roughly one and a half times as large
household incomes. However, among women aged 66
(physician visits for depression within 30 days of hospital
and older who had started antidepressants, those from
discharge) to twice as large (percentage of adults aged
lower-income neighbourhoods were less likely to have
66 and older, starting a new course of antidepressants
had the recommended number of follow up physician
who had three or more physician visits for depression
visits for depression than women from higher-income
within 12 weeks of starting medication; 30-day post-
neighbourhoods. Among Ontarians who had been
discharge rate of emergency department visits) to as
hospitalized for depression, people who lived in higher-
much as four times as large (30-day readmission rate
income neighbourhoods were more likely to have a
for depression).
post-discharge physician visit for depression (and to
71
Figure 5 | S ummary of differences by sex, age, income and LHIN for background
measures and indicators of depression care
Indicator
Stratification Factor
Overall Result
Sex
Age
Income
LHIN
Background Information: Need, Use and Supply of Medical Services (8 measures)
7.4%
Y
Y
Y
Y
Fair or poor self-rated health
29%
N
Y*
N*
N*
No other comorbid chronic medical conditions
33%
Y
Y*
N
N*
Number of days 'out of bed'
13 days
N
Y
N
N
Number of days without cutting down activities
12 days
N
N
N
N
108 per 100,000
Y
Y
Y
Y
OHIP core mental health care users^
15%
Y
Y
N
Y
OHIP core mental health services costs per capita^
$33 per capita
Y
Y
Y
Y
Electroconvulsive therapy (ECT) use
15 per 100,000
Y
Y
N
Y
Number of general practitioners /
family physicians and psychiatrists
19-105 per
100,000
•
•
•
Y
Number of acute hospital psychiatric beds
51 per 100,000
•
•
•
Y
Health and functional status
Primary and Specialty Outpatient Care ( 3 indicators)
Physician visit for depression
40%
N
Y
N*
N*
Three physician visits within 12 weeks of
starting medication
9.6%
N
Y
Y
Y
Physician visit for depression within one year
after giving birth
20%
•
Y
N
Y
Physician visit within 30 days of hospital discharge
63%
Y
N
Y
Y
Time from hospital discharge to first physician visit for
patients seen within 30 days of discharge
9.6 days
N
N
Y
Y
30-day post-discharge rate of emergency department visits
17%
N
Y
Y
Y
7.6%
N
N
N
Y
Acute and Specialty Inpatient Care ( 4 indicators)
• Not applicable
* Based on some values that should be interpreted with caution
^ Confidence intervals for values are extremely small
POWER Study
72
Depression | Discussion
Discussion
Depression, the leading cause of disease-related disability among
women, puts a tremendous burden on the people suffering from
it, their families and society as whole.
Almost five percent of Ontario’s population experiences
and a half times more likely than Ontario men to receive
an episode of depression in any 12-month period.
electroconvulsive therapy (ECT) or be hospitalized for
Women are twice as likely as men to experience
depression.
depression.
8
Among those Ontarians with probable depression in the
Previous research has shown that women’s experiences
community, we found no important differences between
with depression are different from men’s. They tend
women and men in their overall access to physician care
to be younger when they have their first episode of
for depression. Interestingly, the self-perceived health and
depression, have poorer social adjustment and lower
self-reported disability of women and men with probable
19
quality of life
and report more severe episodes and
more chronic depression than men. Men are more likely
to develop alcohol and substance abuse problems
23
and have higher suicide rates.
22
Clearly, depression
depression in Ontario were similar. However, among
individuals who were hospitalized, women were more
likely than men to see their physician after they had been
discharged.
causes great suffering for both sexes and our goal, as
we developed indicators for this chapter, was to help
Age also makes a difference.
ensure high quality mental health care for all Ontarians
Ontarians aged 15-24—the age group with the highest
with depression.
rate of depression—were least likely to see a doctor
We found disparities in depression care in Ontario related
to sex, income, age and geography. The findings suggest
a need for improvement in several areas, including access
to and the distribution and organization of mental health
for the problem. Younger Ontario women were also
more likely than older women to visit an emergency
department within 30 days of discharge after a hospital
care. In particular, our research suggests there may be
Among Ontario seniors who had started a new
breakdowns in care continuity and a need for more
prescription for antidepressants, the oldest women and
collaborative approaches to managing depression—an
men—those aged 81 and older—were the least likely to
area where Local Health Integration Networks (LHINs)
have had the recommended number of physician follow
have an important role to play.
up visits (i.e., three visits for depression within the first
12 weeks) for monitoring their medication use.
Gender makes a difference.
Because women have a higher prevalence of depression
Socioeconomic status makes an even
than men, you would expect that they use depression
bigger difference.
care in greater numbers. For some kinds of care, this
Socioeconomic status was associated with access to
was indeed the case: Ontario women were more likely
care for depression. Ontarians living in the highest-
to visit a physician for depression and were roughly one
income neighbourhoods were more likely to see a
73
physician after a hospital stay for depression, and to
may reflect rural/urban differences (e.g., LHINs with the
do so more quickly, than those living in lower-income
largest urban concentrations tend to have better rates
neighbourhoods. People living in the lowest-income
of physician follow up or visits for monitoring older
neighbourhoods were the most likely to visit an
patients who were starting antidepressant medication).
emergency department after a hospital stay, an
Some of the variation reflects known regional differ-
indicator of suboptimal care coordination during
ences—for example, care in northern Ontario relies
transition from hospital to home. Women with
more on inpatient services58 than in other parts of the
probable depression who were living in the lowest-
province.
income neighbourhoods were more likely than men
and higher-income women to have a physician visit
These differences in use do not reflect
for depression. This could be consistent with a study
differences in need.
that found fewer socioeconomic differences in use
Patterns of use of depression services often did not
of depression care services in Ontario compared to
reflect differences in assessed need. We found patterns
several other jurisdictions. However, more work needs
of depression care across neighbourhood income, rural/
to be done to determine whether this reflects actual
urban residency and LHINs that did not reflect the
use patterns, differences in coding or differential use
prevalence of probable depression (Section 5A). In the
of mental health services not covered by OHIP.
case of neighbourhood income, prevalence and supply
For older Ontarians (aged 66 and older) starting a new
course of antidepressant medication, those from the
highest-income areas were more likely than lowerincome seniors to receive the recommended number of
follow up visits.
of care were opposite; depression rates were highest
among women and men living in the lowest-income
neighbourhoods, but OHIP spending on care was
highest for those residing in the highest-income neighbourhoods. In comparing rural and urban locations,
we found significant differences in care for depression,
although there were no significant differences in
Geography also makes a big difference.
prevalence. Across LHINs, the magnitude and patterns
Rural Ontarians were less likely than urban residents
to have a physician visit for depression after being hospitalized and they had a longer time between hospital
discharge and their first visit. They were also more likely
than urban residents to visit an emergency department
in the month following their hospital stay.
of differences in care were larger than differences in
prevalence. Because there are no consistently accepted
benchmarks, the implications of the mismatch
between indicators of depression care and measures
of prevalence cannot be fully assessed. However, as
noted in Section 5A, it is important to consider why the
The largest and most consistent differences seen were
availability of services seems to have more influence on
across LHINs, where there were significant differences
the care people receive than level of need. More work
in almost every indicator. One exception was ‘percent
is needed to better understand the reasons for these
of individuals with probable depression who had a
differences and barriers to care encountered by specific
physician visit for depression’ where the numbers were
population subgroups.
too small to allow reporting. Some of these differences
74
There are important gaps in depression care
according to guidelines is clinically important. It is also
in Ontario for everyone regardless of sex,
important to assess the management of antidepressant
income, age or where one lives.
therapy in those under age 65. However, this is not
There were gaps everywhere in Ontario, for all
possible using data currently available in the province.
population groups, between the desired or
Finally, we know the most effective treatment for
recommended depression care and the care that was
depression often combines medication and psycho-
delivered. Less than 50 percent of people who reported
therapy.107 While it is possible that psychotherapy is
probable depression saw a doctor for depression in
taking place in more broadly defined follow up visits, it
the year following their interview. This indicator does
seems unlikely given that effective treatment requires a
not include visits to non-medical mental health profes-
lengthier visit and there is a financial incentive to code
sionals, but physicians are the most common provider
these visits using a small set of specified codes. All these
of depression care.7, 67, 101, 102 Because depression is a
findings raise questions about the quality of care being
recurrent disease and often is associated with a 'silent'
delivered to older Ontarians who take antidepressants.
or partly visible disability,103 this finding suggests there
People who have been hospitalized for depression often
are missed opportunities to intervene early in what
have severe and quite debilitating forms of the illness,
becomes a chronic illness for many Ontarians.
but only 63 percent of them had a physician visit for
Less than ten percent of people aged 66 and older
depression in the 30 days after they were discharged.
who started a new course of antidepressant medication
While depression can be stabilized by inpatient care,
received the recommended number of physician follow
continued follow up in the community, including
up visits for depression. It is possible this number
monitoring and treatment by a physician is necessary
underestimates the actual number of people who are
to ensure gains made in hospital are not lost and, for
adequately monitored, because the monitoring may
those taking medication, that problems with side effects
happen during physician visits for other conditions. If
or dosages are addressed.
we assume that is what is happening, then the rate
Up to one-quarter of all hospital stays for depression
of adequate follow up increases to a more reassuring
were followed by a readmission or a visit to the
range of 80 to 90 percent. However, since there is no
emergency department within 30 days of discharge.
definitive way of determining whether antidepres-
Turning to these resource-intensive services within a
sants are being monitored in more broadly defined
fairly short time is a less desirable outcome for patients
physician visits and we know from the literature that
than being maintained with outpatient care and
depression is frequently under-recognized and under-
community support.65
treated in primary care settings and among individuals
with comorbid chronic medical conditions, this is still an
Depression as a chronic illness: the need for
area for concern. This indicator is used internationally
collaborative care.
to assess the quality of depression care and we need
Findings of suboptimal access, quality and outcomes
to improve the capacity to better assess this dimension
of depression care are not new. Reports over two
of depression care through improvements in data
decades and from around the world9, 76, 79, 108, 109 have
comprehensiveness. Individuals with depression are a
consistently documented large gaps where individuals
104, 105
potentially fragile population
pressants have severe side effects,
and some antide-
106
so monitoring
with depression do not seek care or are not recognized
as needing care. Because there is solid evidence that
75
effective treatments for depression are available,
access to psychiatric professionals for advise,
these gaps have led to campaigns to raise public and
consultation and referral.119 Patients who do not
individual awareness of depression and to educate
respond to initial therapy may have their treatment
physicians, families and employers about its nature and
modified by the primary care physician in consultation
severity. But the impact of these campaigns has been
with a psychiatrist, be referred for management by
110-114
a psychiatrist or other mental health professionals or
limited.
referred for additional mental health services depending
The current understanding of depression is that it is a
chronic disease,42 like diabetes or coronary heart disease,
and it may be that past approaches to managing it failed
because they tried single solutions to a complex problem.
Examples from other jurisdictions show that collaborative
care is an effective approach to the diagnosis and
management of depression.13, 14, 109, 115 Collaborative
care is multifaceted, involving the client, providers and
the broader mental health system all at once. Typically:
• Clients are involved in developing their treatment plan
(including setting goals for self-management) and then
are provided with sustained follow up;
upon response to therapy or severity of illness.119
Stepped care is typically a component of collaborative
care models, but may be implemented separately.
Additionally, mechanisms for providing self-management
support to patients either through written materials120
or via the internet121 have been developed and have
shown some benefit.
The internet also holds promise as a tool for prevention,
diagnosis and management of depression. A
web-based, screening instrument for the diagnosis
of depression in primary care shows promise.122 Both
patient information on depression and online cognitive
• Clients’ progress is systematically evaluated and those
evaluations are used to modify the treatment plan;
behavioural therapy have been shown to improve
depression outcomes.121, 123
• Primary care providers work with a multidisciplinary
team including mental health professionals to make and
implement decisions about the client’s care and
• Communication among the care team is systematically
evaluated to identify breakdowns in information flow or
interruptions in care.116, 117
The need for policy and programs to address the
social determinants of inequitable care.
The observed disparities in depression care across
sex, age and geography suggest a need for provinceand LHIN-wide interventions for improvement (see
Improving Depression Care: Different Approaches).
Clients cared for in a collaborative model are more likely
They also highlight the need to address social deter-
to receive evidence-based care, to follow their care plan
minants to reduce the risk of developing depression.
and to report greater satisfaction with their care. Their
There are perennial requests for increased resources
symptoms and functioning improve more rapidly, the
to deliver more services, which would be consistent
benefits last longer and there are greater cost benefits
with some of the background findings we reported in
compared to other forms of depression care.13, 117, 118
Section 5A. However, those findings also suggest that
Other approaches such as stepped care models, patient
a simple increase in the amount of care available is
self-management support and e-health interventions
through use of the internet also hold promise. In
stepped care models, primary care physicians diagnose
and treat mild to moderate depression and have ready
76
not enough. The large variations found by neighbourhood income, rural/urban residency and across LHINs
suggest how resources are distributed and organized
are also important factors in access to care. Importantly,
mechanisms need to be put in place to better measure
telephone can improve outcomes.130, 131 In addition,
access, quality and outcomes of depression care.
Collaborative care models can address both suboptimal
quality and disparities in depression care in primary
care—the main source of formal medical depression
care for most Ontarians. Improved coordination across
telemedicine has been used in rural settings with some
success to improve access to mental health professionals and to adapt the collaborative care model to rural
primary care practices.132
primary care, community agencies and inpatient care
How to reach patients who need care but have not
is particularly important to ensure that people with
sought it is another issue, since many of the studies
more severe and debilitating forms of depression get
we looked at were done in clinics regularly delivering
high quality care. Additional measures used in the
care to members of underserved groups. There is
58
Hospital Report 2007
or under development, such
some evidence that outreach may be effective,133 but
as the number of days psychiatric patients spend
it needs to be tailored and can be time consuming to
in hospital after they have been judged ready to be
establish.134
discharged58 and how long people wait in emergency
to see a psychiatrist124 also suggest a need for more,
and more effective, coordination of mental health
care. Ontario has made some significant investments
in community mental health agencies and programs
such as assertive community treatment and intensive
case management.90 Other initiatives include the
Finally, policy and outreach efforts in mental health care
must be coordinated with larger initiatives. In particular,
policies to address the underlying issues of poverty
and delivering care in diverse geographic location and
policies and programs to better integrate depression
care with other types of health care services, particularly
chronic disease management, can have a tremendous
development of coordinated access programs and
care-planning tables in LHINs and hospitals across the
province125, 126 as well as models for improving postdischarge transitions127 and mental health care in the
emergency room.128 Most of these programs however,
are limited in scope, organized within community-based
services or linking community and hospital-based care.
impact on care for depression.
The need for improved measurement tools.
With the data we have, we can only do a piecemeal
evaluation of coordinated care (see ‘What we can’t
measure’ below). Information on individual sectors of
care—such as we present in this chapter—is valuable,
Research on models of coordinated care shows
but an integrated system of mental health care (the goal
promising results for several groups—men, younger
of several Ontario governments over the years)65, 92, 93
people, older adults and those with low-incomes—all
requires data on transitions between services and their
groups we found had less access to care.
35, 118, 129
While
cumulative contribution to outcomes for depression.
specific outcomes may differ (e.g., some groups take
We have captured some of those transitions in our
longer to show improvement than others), the positive
data, particularly how people contact health services
results appear to be consistent even when models
after discharge from a hospital stay for depression. But
are adapted to allow for the needs of the particular
without integrated data on all sectors of care, we have
populations and providers involved.
116
An important question for Ontario may be how to
only a limited sense of how many people fall through
the cracks, or of who they are.
adapt collaborative care for rural areas, since most of
Indicators used in other jurisdictions to assess
the research has been conducted in large organizations.
depression care, but not feasible with Ontario data, tell
There is some promise that managing depression by
us where efforts to gather better data on coordinated
77
care could begin. In addition, other jurisdictions have
income, can accurately capture an area’s overall
used client satisfaction, cost-effectiveness, timely
characteristics, but they may not reflect the factors
communication among care providers and outcomes
that influence people individually.
(such as symptom or functioning levels) to evaluate
the success of coordinated care, which Ontario could
also consider.
Thirdly, the data in this chapter are not current—they
date from 2001 and 2005/06. However, they provide
a baseline for comparison as newer information
becomes available.
Limitations
As noted throughout this chapter, these indicators
What we can’t measure
have a number of limitations that need to be
As we developed the indicators for this chapter, we
considered in their interpretation. The indicators
indicate where disparities are likely and it is possible
to track them across time to assess progress. They do
not include enough detail to explain why disparities
occur, so they cannot dictate solutions.
found several aspects of depression care we could not
measure, because of three main barriers. For some
potential indicators, there were no Ontario-wide data.
For example, none of the measures relating to care in
community mental health settings could be calculated
Secondly, there are limitations inherent in the data.
at the time of writing. In addition, no data on ethnic
Administrative data in a universal health system
or minority status were available. More comprehen-
have the advantage of capturing the breadth of the
sive data are needed to assess quality and outcomes
population but provide little clinical or risk factor
of depression care in primary care, speciality care and
information. They can show access to broadly defined
hospital settings.
categories of care, but cannot illustrate the quality or
adequacy of care received. Administrative data also
For example, there is a lack of measurable indicators for
are uneven in the accuracy of what they record. For
depression care outside of the formal medical setting—
example, in the OHIP data, diagnostic information is
not audited and is limited to one field. Individuals with
both depression and another illness may have their
physician visit attributed to that other illness, leading to
under-counting of depression care. On the other hand,
they may be over-counted—one of the codes used to
identify depression in this chapter (OHIP diagnostic code
300) is non-specific and also the single most frequently
used code by primary care physicians.78
were unable to address that gap, largely because we
do not know what types of prevention and promotion
activities are most effective for depression.135 The
thinking is that targeted initiatives aimed at groups at
greater risk for developing depression are effective,42
but there is limited evidence on which methods work
for which groups.
of the population. For example, we could not assess
of information on individuals, may be influenced
monitoring of antidepressant therapy for those under
by reporting biases, recall biases and subjective
interpretation of the participants. Census data, which
78
specifically, for prevention and promotion activities. We
Some indicators could only be measured for a subset
Survey data, while they usually contain a wealth
were used in this chapter to define neighbourhood
Some domains lacked adequately researched indicators.
age 65. The need to closely monitor antidepressant
therapy is important for all age groups.
Finally, there were evidence-based indicators for
or electroconvulsive therapy). Such small numbers are
which Ontario data were available but could still not
a problem both statistically (because they cannot be
be reported. Despite relatively large sample sizes (the
reported with any confidence) and ethically (because
smallest being 39,000 Ontarians in the CCHS 1.1
reporting them might violate privacy and confidentiality
survey) these indicators measured events that were very
guidelines). We suspect similar limitations will apply to
rare. Small sample sizes prevented us from reporting
many clinically important measures, particularly those
the percentage of ‘depressed’ individuals who were
on interventions or outcomes specific to subgroups of
either taking medication or had a physician visit for
people suffering from depression.
depression, who had a serious outcome (such as a
suicide attempt, an emergency room visit for depression
Key Messages
Our findings support the need to re-evaluate care for
• Explore developing care models for specific underserved
depression in Ontario along several fronts and at several
groups (including men, younger people, the elderly,
levels. The indicators chosen for this chapter arise from
people with low incomes and people who live in rural
evidence-based recommendations or guidelines for
areas) and evaluate their impact, especially when
appropriate depression care and suggest specific and
combined with targeted outreach;
immediate aspects of clinical practice that need further
examination and improvement. The distribution and
organization of existing resources—an important
element in supporting the continuity of care envisioned
across the decades of Mental Health Reform in
• Implement models to better coordinate care through
transition periods between sectors, particularly from
hospital to home;
• Coordinate depression care with other types of health
Ontario and an obvious focus for the newly organized
care, particularly chronic disease management, so that
LHINs—will also play important roles in both improving
patients with more than one health problem do not
access and delivering more appropriate and effective
receive fragmented care;
courses of care in the immediate and medium term. In
• Evaluate the effectiveness of care through routine
particular, a wider adoption of collaborative care models
gender and equity analyses of indicators of depression
for depression deserves serious consideration.
care and its outcomes;
The following actions could help to improve access to,
and the quality of, depression care in Ontario:
• Develop and support collaborative care models in
• Improve data capacity to better measure access,
quality and outcomes of depression care across the
care continuum.
primary care and across depression care sectors;
79
Improving Depression Care:
Different Approaches
In this chapter we present results pertaining to patterns of
depression care in Ontario with a focus on gender and equity
issues. We identified many opportunities for improvement.
Measurement is only the first step towards improving
care physicians are provided the support they need
care. Once gaps in care are found, identification and
to effectively manage depression and ready access to
implementation of interventions to improve care are
mental health professionals for both shared care and
essential next steps. Quality improvement interven-
referral for more complex cases. Patients are commonly
tions can take many forms, but are usually targeted
provided with self-management support. An adaptation
at the policy, practice, provider or patient levels or a
of the collaborative care model for people on short-term
combination of these. Because women have different
disability leave for psychiatric disorders in Ontario was
patterns of depression and different experiences
found to be effective in a recent trial.140
with care, the provision of depression care should be
sensitive to these differences. There are a number of
evidence-based interventions available to improve
depression care. In addition, much work in Ontario and
internationally is aimed at developing new approaches
to improving access, quality and outcomes of care
Collaborative care has proven effective at improving
both short- and long-term depression outcomes as well
as reducing gender, socioeconomic and racial disparities
in care.52, 72, 118 In addition, the model is effective across
age groups including older adults141 and adolescents.129
among individuals with depression. Below we provide
Multiple large scale randomized controlled trials have
selected examples of both well studied, evidence-based
found collaborative care for depression to be effective.
interventions to improve depression care as well as
However, knowledge that a model works does not
emerging models where there is some evidence that
necessarily ensure that the model will be widely
they can lead to improvements in care, but the evidence
implemented. Much work has been done to implement
is limited.
these models into real-world primary care practice and
there is growing evidence on how to do this effectively.
Collaborative care
Large scale projects that have made headway in
A body of evidence from randomized controlled trials
developing quality improvement strategies to implement
and supported by systematic reviews has found col-
collaborative care models into real-world primary care
laborative care models to be an effective approach for
practices include Improving Mood-Promoting Access
improving quality and outcomes of depression care
to Collaborative Treatment (IMPACT), Re-Engineering
in primary care settings.72, 136-138 This approach uses a
Systems for Primary Care Treatment of Depression
team of health professionals (including primary care
(RESPECT-Depression) project142-144 Partners in Care145, 146
physicians, allied health professionals and psychiatrists)
and Translating Initiatives for Depression into Effective
to ensure proactive treatment and follow up care of
Solutions (TIDES) project.147-149 For example, IMPACT is
depressed patients (see the Discussion).137, 139 Primary
an effective collaborative care model for older adults
80
that incorporates a depression care manager, routine
The National Alliance on Mental Illness (NAMI)
outcomes assessments, psychiatric consultation when
undertook the goal of promoting the ACT model in
needed and a stepped care approach.141, 150, 151 IMPACT
order to improve access to this evidence-based service-
has been implemented into many settings.129, 152-154
delivery model.165 Through strong advocacy, education
Many of these programs have also made materials
and dissemination of implementation resources, NAMI
and resources available online to assist clinicians and
has created a grassroots demand for ACT programs
organizations interested in adapting and implementing
and has worked with providers to establish ACT
the projects into their unique care settings.142, 145, 155
programs.166
Examples of successful implementation of this model
are also available on the IMPACT website.
The Implementing Evidence-Based Practices for Severe
Mental Illness project,166, 167 an initiative to improve
These projects have shown quality improvement efforts
access to empirically supported practices for people
in primary care settings can improve depression care
with severe mental illness, has developed and made
and outcomes of depressed patients.
available an Assertive Community Treatment Evidence-
12-14
Based Practice KIT to aid service providers in implementAssertive community treatment
ing ACT services.168
Assertive community treatment (ACT) is a communitybased model for delivering treatment and support
to people with severe and persistent mental illness,
including severe depression. Rather than a case-management system which provides referrals to outside
services, ACT services are delivered directly by a multidisciplinary team of service providers who have expertise
in areas of psychiatry, social work, nursing, substance
abuse treatment and vocational training. These services
are delivered in home or community settings and are
available 24 hours a day, 7 days a week.
156
It is often challenging to adapt a model implemented
in a rigorously designed trial into routine practice. ACT
models have been implemented in Ontario. However,
a recent study identified challenges to full implementation of the model.169 These findings have led to
changes to the implementation strategy, illustrating the
importance of formally evaluating practice innovations
and improvement initiatives.
Performance measurement and reporting
Performance measurement and reporting is one
Multiple studies from the US have shown ACT programs
strategy for improving health care quality. Important
can reduce hospital days, while improving quality of
progress has been made in the development and
life and functioning.157-161 ACT has also been shown to
testing of quality indicators for depression care in
improve additional outcomes such as increased housing
both ambulatory care and hospital settings, though
stability and reduction in jail days. ACT programs
indicator development in this area lags behind other
have been show to be cost-effective when the model
sectors.86, 170-172 In the US, the National Committee
is faithfully implemented and high risk patients are
on Quality Assurance’s (NCQA) Health Plan Employer
targeted.162 Studies from the UK and Europe have
Data and Information Set (HEDIS), a tool used by
had more modest results when comparing ACT to
more than 90 percent of American health plans to
community mental health care teams, which may in
measure performance on important dimensions of
part reflect the effectiveness of usual mental health
care, contains five measures relating to mental health
care in those settings.163, 164 These trials found improved
(three assessing the management of antidepressant
patient engagement, satisfaction and reduction in loss
therapy in ambulatory care settings and two assessing
of contact with the mental health system.163, 164
follow up care after hospitalization for mental illness).
81
Recently an expert consensus process was used to
advocacy, education, indirect and direct client interven-
identify a set of fifteen quality indicators to assess
tion and follow up. It was developed to eliminate gaps
hospital care for mental illness, including measures
in mental health care and build collaborative cultures
for care coordination in the transitions from home to
between the local hospital, physicians' offices, mental
hospital and back to the community.172
health clinics, and community agencies. The goal was
The impact of measurement and reporting of HEDIS
depression measures has been assessed. Only modest
improvements have been made on these performance
measures over time and rates of improvement have
been much smaller than for other chronic
to address unmet need for mental health services in this
rural community.175 In Winnipeg, psychiatric emergency
nurses based in emergency departments have been
used to support the care of patients presenting to the
emergency department for mental health problems.176
One challenge in implementing the mental health
conditions.73, 86, 170, 171 This finding underscores
liaison role has been clear definition of the roles and
the unique challenges to improving mental
health care and the need for health system redesign
to achieve improvements in depression care.
responsibilities of the mental health liaison. More
information is needed on the impact of this role in
different care settings on patient outcomes as well as
Furthermore, there is need for development of
on the cost effectiveness of different models of this
more comprehensive and sensitive indicators in
function.
depression care.
E-Health and web-based interventions
Integration and coordination of mental health
E-health and web-based interventions are increas-
services
ingly being used to improve access to depression care
The need to integrate and coordinate mental health
and provide self-management support and depression
services across the continuum of care (see Figure 1)
education to patients, support primary care physicians,
is well recognized and local systems are working to
integrate and coordinate depression care and provide
implement innovative approaches to this problem.
early intervention and prevention.121-123 Telemedicine
However, there is limited evidence as to how do this
most effectively and efficiently. Nevertheless, a number
of approaches show promise, albeit evaluated in single
systems of care with limited data on patient outcomes.
can be used increase access to mental health professionals. One randomized control trial found telemedicine effective in adapting the collaborative care model
of depression care to rural communities. The Ontario
Care coordinators have been shown to improve
Telemedicine Network is using telemedicine to deliver
outpatient follow up both at 7 days and 30 days after
psychiatric care to those who otherwise would have
a psychiatric hospitalization.173 Nurse-led mental health
difficulty accessing these services (see the Discussion).
liaison services have been implemented in Australia
and the United Kingdom.174 The mental health liaison
nurse serves as a care coordinator, provides support
to patients, education and support to providers, and
may function as a member of a multidisciplinary team
providing care.174
There are a growing number of web-based interventions for depression directed both at patients and
providers. The internet also holds promise as a tool for
prevention, diagnosis and management of depression.
Delivery of both patient information on depression and
online cognitive behavioural therapy has been shown to
In Canada, one Alberta Health Region has implemented
improve depression outcomes in a randomized control
a mental health liaison role in a rural community. The
trial in Australia.121, 123 The investigators hypothesized
role was filled by a mental health nurse who provided
82
that providing depression education and training in
been shown to reduce racial disparities in depression
cognitive behavioural therapy to adolescents and
care.52, 183 One study found that racial differences in
young adults can foster resilience and behaviours to
receipt of counselling was explained by education,
help prevent depression. This web-based program also
employment status and insurance status.181 Thus, care
provides self-management support to patients receiving
needs to be provided in the context of intersecting
depression care.121 A web-based screening instrument
factors of gender, ethnicity and socioeconomic position.
for the diagnosis of depression in primary care has also
It is recommended that clinicians consider patients'
been tested.122 It is likely that there will be growing
cultural and social context when negotiating treatment
availability of a range of e-health interventions and
decisions for depression.177
web-based interventions for depression. More evidence
will be needed about their effectiveness for specific
purposes in different settings as well as effectiveness in
different population subgroups.
Improving accessibility, acceptability and
outcomes of depression care among racial and
ethnic minorities
Depression care needs to be accessible and acceptable
and delivered in a culturally sensitive manner to
immigrants and ethnic minorities who may have
different cultural beliefs about depression and different
preferences for care.177, 178 Different population
subgroups may also encounter different barriers to care
and have different experiences within the health care
system.179 Furthermore, there is evidence that patientphysician communication may differ across diverse
population sub-groups.180 Language may also provide a
barrier to depression treatment.
In addition to collaborative care a number of different
approaches are being studied to improve the cultural
acceptability and sensitivity of depression care and
to improve the effectiveness of depression care to
diverse populations. For example, low-income women
may benefit from case management to address other
social issues. The literature suggests models that
allow patients to select the treatment of their choice
(medication or psychotherapy or a combination) while
providing outreach and other supportive services (case
management, childcare and transportation) appear
to result in optimal clinical benefits for disadvantaged
women suffering from depression.184 A culturally
tailored videotape about depression was found to be
acceptable for most African Americans with depression
participating in focus groups and improved knowledge
and several attitudes about depression.185 While more
evidence is needed on how to best tailor depression
care to diverse communities and what strategies best
Racial disparities in depression care in primary care have
optimize outcomes the evidence supports the idea
been observed but not in all studies, suggesting that the
that high quality, culturally acceptable depression care
presence of disparities varies across practice settings and
coupled with supports that address social context
that it is possible to close care gaps associated with race
can lead to improved outcomes for all patients with
and ethnicity.
depression.
181, 182
A quality improvement intervention
using the collaborative care model in primary care has
83
Appendix 5.1
Indicators and their links to provincial strategic objectives
APPENDIX 5.1 | D
epression indicators: links to the Ontario Health Quality Council
(OHQC) Attributes of a High-Performing Health System and
the Ministry of Health and Long-Term Care (MOHLTC) Strategic
Objectives
Indicator
Link(s) to OHQC Attributes of a
High-Performing Health System
Link(s) to MOHLTC
Strategic Objectives
• Accessible
• Improve
Section 5A – Background Measures
clinical and population
health outcomes
• Effective
• Focused
on population health
• Influence
• Improve
Health and functional status of people
with probable depression
• Effective
• Focused
broader determinants
of health
health status of Ontarians
• Improve
health outcomes
• Influence
broader determinants
of health
• Improve
• Accessible
• Improve
health outcomes
• Effective
• Influence
broader determinants of
health
• Improve
OHIP core mental health care users
and OHIP core mental health care
costs
• Accessible
• Focused
• Increase
productive use and
appropriate distribution of resources
across the system
• Improve
access to appropriate health
services
• Accessible
• Effective
84
• Increase
productive use and
across the system
Depression | Appendix 5.1
APPENDIX 5.1 | D
epression indicators: links to the Ontario Health Quality Council
Objectives
Indicator
Link(s) to MOHLTC
• Accessible
• Increase
Number of general practitioners (GPs)/
family practice (FP) physicians and
psychiatrists
productive use and
across the system
• Improve
access to appropriate
health services
Number of acute hospital psychiatric
beds
• Accessible
• Increase
productive use and
across the system
• Improve
access to appropriate
health services
Section 5B – Primary and Specialty
Outpatient Care
Percentage of individuals with probable
depression who had a physician visit
for depression
• Accessible
Percentage of older adults starting
a new course of antidepressant
medication who received adequate
physician follow up
• Effective
Percentage of women who had a
physician visit for depression within
one year of giving birth
• Accessible
• Patient-centered
• Improve
• Improve
services
patient-centeredness
• Improve
safety and effectiveness of
health services
• Improve
chronic disease management
• Improve
services
• Improve
patient-centeredness
85
APPENDIX 5.1 | Depression
indicators: links to the Ontario Health Quality Council
Objectives
Indicator
Link(s) to MOHLTC
• Effective
• Improve
Section 5C – Acute and Specialty
Inpatient Care
30-day post-discharge rate of physician
visits for depression
• Integrated
integration of health services
providers, processes and systems
• Improve
health services
• Improve
Average number of days post-discharge
to first physician visit for depression
• Accessible
• Improve
• Integrated
• Improve
services
• Improve
30-day post-discharge rate of
emergency department visits (with no
subsequent hospital admission)
• Accessible
• Improve
• Effective
• Integrated
• Improve
health services
• Improve
• Accessible
• Effective
• Improve
• Improve
health services
• Improve
86
Appendix 5.2
INDICATORS AND THEIR SOURCES
APPENDIX 5.2 | D
epression indicators: indicator sources and data sources
Measures and Indicators
Indicator Source
Data Source
• A
Canadian Community Health Survey
(CCHS), Cycle 1.1
Profile of Women’s Health
Indicators in Canada186
• Association
of Public Health
Epidemiologist in Ontario (APHEO)
Health and functional status of people
with probable depression
• A
Profile of Women’s Health
Indicators in Canada186 ^
• Statistics
CCHS, Cycle 1.1
Canada. Health Indictors
2008^
• Association
of Public Health
Epidemiologist in Ontario (APHEO)^
• Report
of the Consultative Meeting
to Finalize a Gender-sensitive Core
Set of Leading Health Indicators187^
• Hospital
Report 2004: Mental
Health188
Canadian Institute for Health
Information Discharge Abstract
Database (CIHI-DAD);
OHIP core mental health care users
and OHIP core mental health care
costs per capita
• ICES
Ontario Health Insurance Plan (OHIP);
RPDB
Atlas: Fee-for-Service Core
Mental Health Services: Changes in
Provider Source and Visit Frequency60
• Accountability
and Performance
Indicators for Mental Health Services
and Supports: A Resource Kit189
• Electroconvulsive
Therapy in Older
Adults: 13-year Trends190
OHIP; RPDB
• Epidemiological
Analysis of
Electroconvulsive Therapy in Victoria
Australia191
87
APPENDIX 5.2 | D
Indicator Source
Data Source
• Accountability
ICES Physician Database (IPDB);
RPDB
Number of general practitioners
(GPs)/ family practice (FP) physicians
and psychiatrists
and Performance
• Psychosocial
Wellbeing and
Psychiatric Care in the European
Communities: Analysis of Macro
Indicators192
• Hospital
Report 2004: Mental
Health188
Number of acute hospital
psychiatric beds
• Accountability
and Performance
• Psychosocial
Daily Census Summary Report Mental
Health Beds online, Ministry of Health
and Long-term Care (MOHLTC) Health
Data Branch; RPDB
• Continuous
CCHS, Cycle 1.1; OHIP
Wellbeing and
Psychiatric Care in the European
Communities: Analysis of Macro
Indicators192
Section 5B – Primary and Specialty
Outpatient Care
Percentage of individuals with probable
depression who had a physician visit
for depression
Enhancement of Quality
Measurement in Primary Health Care
(CEQM), BC
• Women's
Health Surveillance Report:
A Multi-Dimensional Look at the
Health of Canadian Women193
88
Percentage of older adults starting
a new course of antidepressant
medication who received adequate
physician follow up
• The
National Committee for Quality
Assurance (NCQA). Healthcare
Effectiveness Data and Information
Set (HEDIS)
Ontario Drug Benefit (ODB) database;
OHIP
Percentage of women who had a
physician visit for depression within
one year of giving birth
• National
CIHI-DAD; OHIP; ICES Mother-Baby
(MOMBABY) Linked database
Health Priority Areas Report:
Mental Health 1998, Australia194
APPENDIX 5.2 | D
Indicator Source
Data Source
• Hospital
CIHI-DAD; OHIP
Section 5C – Acute and Specialty
Inpatient Care
physician visits for depression
Report 2004: Mental
Health188
• The
National Committee for Quality
Assurance (NCQA), Healthcare
Effectiveness Data and Information
Set (HEDIS)
Average number of days post-discharge
to first physician visit for depression
• Continuous
Enhancement of Quality
Measurement in Primary Health Care
(CEQM), BC
CIHI-DAD; OHIP
• A
Mental Health Program Report
Card: A Multidimensional Approach
Monitoring in Public Sector
Programs195
emergency department visits (with no
subsequent hospital admission)
• Hospital
Report 2004: Mental
Health188
CIHI-DAD; National Ambulatory Care
Reporting System (NACRS)
• Hospital
CIHI-DAD
Report 2004: Mental
Health188
• Accountability
and Performance
^ These references examine self-rated health and self-reported functional status in the general population.
89
Appendix 5.3
How the Research was Done
1. Indicator Selection and Reporting
The Working Group then reviewed these potential
The indicators reported in this chapter were selected
indicators using three filters. First, items that were
using a modified Delphi process combined with a
descriptive measures (e.g., prevalence of depression)
structured literature review. The process began with a
were set aside from those that were more direct
review of a continuum of care framework that spanned
indicators of depression care (e.g., percentage of
seven types of services ranging from prevention through
population receiving preventive screening). The
palliative care services. The project team decided to
substantial number of items identified as ‘descriptive’
exclude palliative care from consideration as issues
in this process led the team to add Section 5A of this
related to depression care in this setting are complex
chapter as these measures provide important contextual
and could not be readily assessed.
information about disease burden in the population,
The remaining six service types (Figure 1) were the basis
need for services and patterns of care.
for a survey to be completed by an expert panel. In this
Second, the Working Group evaluated the remaining
survey, panel members were asked to identify the two
items in terms of their importance and relevance
most critical issues for each service continuum point
to the chapter’s purpose. Examples of items judged
that represented 1) a gap between women and men
less relevant include measures of specific rather than
in the treatment for depression or in the exposure to
broader types of intervention (e.g., lithium therapy) or
negative or positive factors associated with depression
of outcomes more relevant to specific program types
incidence, course of the illness, access or use of services,
(e.g., percent of clients employed within six months
and/or outcomes and/or 2) a substantial issue in the
post diagnosis).
care of depression. ‘Substantial’ was defined in terms of
Third, because the goal of the POWER Study was to
the size of the affected population or the severity of the
report actual numbers, candidate indicators were
associated outcome. Participants were also to provide a
reviewed in terms of whether or not they could be
rationale for each issue so that these could be incorpo-
measured using available Ontario-wide data. This
rated into the subsequent Delphi process.
feasibility filter was applied somewhat liberally with
Twenty-six issues were identified by the panel (Table
the intent of maximizing the number of measurable
5.1), which then served as the basis for a structured
candidate indicators. In some cases, similar indicators
review of both published and grey literature. One
were merged into a single, more easily measured, item.
hundred and twenty measures were identified through
In other cases, proxy or interim measures were used as
this search with primary care measures accounting
‘placeholders’ for indicators that could not be measured
for the vast majority (76) followed by acute/specialty
in their original form. The application of these three
inpatient care (23). Because no indicators were found
filters reduced the number of candidate indicators to
for ‘chronic and rehabilitation care’, this continuum
thirteen.
point was dropped from consideration.
90
The final set of indicators was selected through a
most responsible diagnosis included an ICD-10 code
modified Delphi process by a Technical Expert Panel
for major depression (ICD 10 codes F32, F33, F412 or
using a two-step method—first through an online ques-
F480). For the Ontario Health Insurance Plan (OHIP)
tionnaire using explicit indicator selection criteria and
physician claims’ data, the diagnostic codes were those
then at a face-to-face meeting on April 4, 2007 (see
that included depression (311) or reactive depression
Introduction to the POWER Study, chapter 1 for a more
(300) in their descriptions.
detailed description of the Delphi process. See Appendix
5.1 or 5.2 for a complete list of reported indicators).
The definition of a physician visit for depression used
in this chapter is imprecise because it can both under-
Indicators and background measures were calculated
and over-report whether depression, versus other
at the provincial and Local Health Integration Network
conditions, was addressed during the visit. The OHIP
(LHIN) levels. They were first stratified by sex and then
database only allows one diagnosis per visit, irrespec-
by age, income (either neighbourhood income quintile
tive of the number of conditions that are addressed
or annual household income), and rural/urban residency,
during the visit, thus contributing to under-reporting
when sample size allowed. Age-adjustment was done
of depression. However, one of the diagnostic codes
using indirect standardization.
(300: Anxiety neurosis, hysteria, neurasthenia,
obsessive compulsive neurosis, reactive depression)
2. Data Sources and Measures
used to define a physician visit for depression in this
The data presented in this chapter came from several
chapter is overwhelmingly the one most frequently
sources, including survey and administrative data.
used in family physician practice, suggesting an
In most cases, administrative data from fiscal year
overuse of this code. This code is not specific to
2005/06 were used, however for those indicators
depression, therefore, including it in the definition may
based on linked administrative and CCHS, Cycle 1.1
over-report visits for depression, to some extent, and
data, fiscal years 2000/01 and 2001/02 were used to
may counterbalance under-reporting of depression
maintain a consistent time frame. The administrative
due to the one available diagnostic field.78 When this
data sources that were used in producing this chapter
definition is tied to a person having depression (see
are described below.
’Measuring Depression’ box in the Introduction of this
The indicators included measure the percentage
of individuals aged 15 and older with probable
depression (based on survey data) and those who
chapter) or a prescription for an antidepressant, it may
even more closely indicate a visit in which depression is
addressed.
received care for depression (based on routinely
The denominators for indicators based upon 2005/06
collected administrative data or linked survey and ad-
administrative data were derived from 2005 estimates
ministrative data). Depression-related service contacts
obtained from the Registered Persons Database (RPDB).
were defined using the diagnostic information
The RPDB overestimates the number of people living
available in each database or, in the case of the
in Ontario. This overestimate was corrected by using a
Ontario Drug Benefits (ODB) database, the drug
methodology that adjusts the RPDB so that population
information numbers (DIN) associated with antidepres-
counts by age and sex match estimates from Statistics
sant medication. For the Canadian Institute for Health
Canada.
Information Discharge Abstracts Database (CIHI-DAD)
an encounter was defined as depression-related if the
91
Canadian Community Health Survey (CCHS)
comparative picture of differences in depression care
The CCHS is a nationally representative cross-sectional
across sociodemographic and geographic groups.
survey of the Canadian community-dwelling population
Two other limitations of the CCHS, Cycle 1.1 data
conducted every two years by Statistics Canada. It
should be noted. First, the depression questions were
is conducted via face-to-face interviews and covers
optional and one Ontario public health unit/region
material that alternates between a general overview
(Brant) opted not to include these questions for their
of the health of Canadians (the x.1 cycle surveys) and
region. The impact is that the prevalence of probable
more in-depth issues (the x.2 cycle surveys). Residents
depression may be under- or over-reported for the
living on Indian Reserves and on Crown Lands, insti-
Hamilton Niagara Haldimand Brant LHIN. This may
tutional residents, full-time members of the Canadian
impact the overall finding that there was geographic
Armed Forces and residents of certain remote regions
variability in the prevalence of probable depression
are excluded.
and that the patterns of use and supply did not match
The two surveys considered for use for this chapter on
the patterns of need. Second, the CCHS, Cycle 1.1
depression were Cycles 1.1 (2000/01) and 1.2 (2002).
sampling method was designed around health regions
Cycle 1.2 includes a more comprehensive assessment
since the LHINs did not exist at the time of the survey.
of depression than Cycle 1.1. However, because the
This may introduce some error into the estimates
linkable version of Cycle 1.2 was not available at the
reported for the LHINs.
time of this reporting, only data from Cycle 1.1 were
The studentized range test was used to assess the
used.
significance of differences among the rates. For the
Background measures and indicators using the CCHS
indicators based on the CCHS, Cycle 1.1 data, the
data were restricted to Ontario respondents aged 15
standard errors of the rates and 95 percent confidence
and older since depression is an illness that appears
intervals were calculated using 500 bootstrap weights
in the late teens as well as in later years. Past-year
provided by Statistics Canada. In addition, relative rates
depression was measured in Cycle 1.1 using a cut-off
were calculated for women-to-men, lowest-to-highest
score of 0.9 on the Composite International Diagnostic
neighbourhood income quintile and rural-to-urban
Interview-Short Form for Major Depression (CIDI-SFMD).
residence.
The CIDI-SFMD probability score of >0.9 was considered
Statistics Canada rules were followed in the reporting of
to predict probable depression. Since the CIDI-SFMD
estimates using the Ontario share file as follows:
was designed to predict the probability that a person
would be considered depressed using the full set of
CIDI depression questions (as was done in Cycle 1.2), it
may somewhat overestimate prevalence. The prevalence
of depression based on Cycle 1.2 was 4.8% (6.1% of
women, 3.5% of men) compared to the rate of 7.4
• Estimates should not be reported if the unweighted
sample is less than 10
• Estimates are adequate and can be reported if the
coefficient of variation is 16.5 or less
• Estimates should be reported with caution if the
(9.8% of women, 4.9% of men) from Cycle 1.1 which
is reported in this chapter. It should be noted that the
CIDI-SFMD has not yet been fully validated.196 Thus
coefficient of variation is between 16.6 and 33.3
• Estimates should be suppressed if the coefficient of
variation is greater than 33.3
the prevalence reported here is not precise and very
likely somewhat overestimates the actual population
prevalence. However, it is still useful in providing a
92
Ontario Health Insurance Plan (OHIP)
The Ontario Drug Benefit Program (ODB)
The OHIP claims database covers all reimburse-
The ODB database contains information about the use
ment claims to the Ontario Ministry of Health and
of medications, including antidepressants, in Ontarians
Long-Term Care, made by fee-for-service physicians,
aged 65 and older as well as individuals on welfare
community-based laboratories and radiology facilities.
assistance who are covered by the ODB. The ODB
The OHIP database at ICES contains encrypted patient
tracks all filled prescriptions for medications listed in its
and physician identifiers, code for service provided,
Formulary.
date of service and the associated diagnosis and fee
paid. Services which are missing from the OHIP claims
ICES Physician Database (IPDB)
data include: some lab services, services received in
The IPDB contains information on physician demo-
provincial psychiatric hospitals, services provided by
graphics and specialty training. The IPDB incorporates
health service organizations and other alternate funding
information from the Corporate Provider Database
plans, diagnostic procedures performed on an inpatient
(CPDB), the Ontario Physician Human Resource Data
basis and lab services performed at hospitals (both
Centre (OPHRDC) database and the OHIP database
inpatient and same day). Also excluded is remuneration
of physician billings. The CPDB contains information
to physicians through Alternate Fee Plans (AFPs). Their
about physician demographics, specialty training and
concentration in certain specialties or geographic areas
certification and practice location. This information is
could distort the analysis.
validated against the OPHRDC database, which verifies
this information through periodic telephone interviews
Canadian Institute of Health Information
with all physicians practicing in Ontario. The number
Discharge Abstracts Database (CIHI-DAD)
of physicians per 100,000 population was derived
The CIHI-DAD is a database of information abstracted
from the IPDB and census population estimates for
from hospital records. It includes patient-level data
2005.
for acute and chronic care hospitals, rehabilitation
hospitals and day surgery clinics in Ontario. The main
ICES Mother-Baby (MOMBABY) Linked Database
data elements of the CIHI-DAD database are encrypted
The MOMBABY dataset is a cumulative database
patient identifier, patient demographics (age, sex,
created by linking the CIHI-DAD inpatient admission
geographic location), diagnoses, procedures and ad-
records of delivering mothers to those of their
ministrative information (institution number, admission
newborns. The linking algorithm makes use of maternal
category, length of stay).
and newborn chart numbers, institutions, postal codes,
admission/discharge dates and procedure codes. The
National Ambulatory Care Reporting System
database includes information on maternal gestational
(NACRS)
age at admission and at delivery, newborn gestational
NACRS is a data collection tool used to capture patient
weeks at delivery and flags that identify multiple births
and clinical information on patient visits to hospital
and still births.
and community-based ambulatory care: day surgery,
outpatient clinics and emergency departments. It
is currently mandated in Ontario for emergency
department, day surgery, dialysis, cardiac catheterization
and oncology facilities.
93
Linked Data Measures (Administrative and/or
estimates were calculated by DA. Ontario neighbour-
Survey Data)
hoods are classified into one of five approximately
The linked indicator for individuals with probable
equal-sized groups (quintiles), ranked from poorest (Q1)
depression was defined using the CCHS, Cycle 1.1.
to wealthiest (Q5). These income quintiles are used
CCHS data were linked to the administrative data using
as proxy for overall SES, which has been shown to be
the scrambled unique identifier available across all the
related to population health status and levels of health
databases used in this chapter. The time period for the
care utilizations. Individual geographic information
administrative data included was based on the CCHS
from ICES databases was used to define the best
interview date and the indicator. The linkage was with
known postal code for each person on July 1 of each
administrative records within one year after the CCHS
year (available from 1991 to 2004). Postal codes were
interview.
then used to assign people to Enumerations Areas
(EAs) or Dissemination Areas (DAs) (using the Statistics
Indicators for depression (e.g., physician visits for
Canada Postal Code Conversion File) and thus to one
depression) were defined using the diagnostic
of the income quintiles. EAs and DAs are small adjacent
information in the various administrative data as
described earlier. The date of the referent event (e.g.,
hospital discharge) was used to determine the time
geographic areas, designated for collection of census
data. DAs replaced EAs in 2001 and have a population
of 400–700 persons.
period of the other administrative data to be linked
(e.g., emergency department (ED) visit within 30-days
post-discharge).
Annual Household Income
Annual household income was collected in the CCHS,
Cycle 1.1. Taking the number of household members
3. Regional and Socioeconomic Variables
into consideration, annual household income was
Patients Residence
classified into four categories: low income, lower
For all analyses presented in the report, the definition
middle, middle or higher income. Low income was
of ‘Local Health Integration Network (LHIN) of patient
defined as <$15,000 for 1 or 2 household members,
residence’ is based on the postal code of the individual
<$20,000 for 3 or 4 household members or <$30,000
at the time of completing the survey for CCHS data, the
for 5 or more household members. Lower middle
postal code at the time of discharge for CIHI-DAD data
income was defined as $15,000 to $29,999 for 1
or the postal code of the individual as of July 1, 2005
or 2 household members, $20,000 to $39,999 for
for data from OHIP or the ODB.
3 or 4 household members or $30,000 to $59,999
for 5 or more household members. Upper middle
Income Quintile
income was defined as $30,000 to $59,999 for 1 or 2
Average neighbourhood income is calculated by
household members, $40,000 to $79,999 for 3 or 4
Statistics Canada and is updated every five years
household members or $60,000 to $79,999 for 5 or
when new Census data become available. Income
more household members. Higher income was defined
was calculated using the neighbourhood income per
≥$60,000 for 1 or 2 household members or ≥$80,000
person-equivalent (IPPE), which is a household-size
for 3 or more household members.
adjusted measure of household income based on 2001
census summary data at the dissemination area (DA)
and using person-equivalents implied by the 2006
low income cut-offs (LICOs). In 2001, average income
94
Location of Residence (Rural Versus Urban)
Because of issues of sample size and high sampling
Rural/urban residency was assigned based on postal
variability of the responses to these questions, we report
code and using the Statistics Canada PCCF+ macro to
the indicators as described above.
assign locations. Community size was derived from the
Statistics Canada 2001 Census data. Communities of
Measures of Health Service Use
10,000 or fewer residents were defined as rural. All
Administrative data were used to measure health
other communities were classified as urban.
service use. While the original intent was to include the
12-months of data within a single fiscal year (i.e., from
Standardization
April 1 to March 31), this had to be modified. CIHI-DAD
All indicators were age-adjusted to the study cohort
and NACRS data are released for analyses in 12-month
using indirect standardization.
blocks corresponding to a fiscal year. However, two
indicators (30-day readmission rate and 30-day post-
4. BACKGROUND MEASURES AND INDICATORS
discharge rate of ED visits) required the capability of
following up one month after the fiscal year ended.
Prevalence of Depression
The solution was to shift the 12 months back by one
The prevalence of depression was measured using
month—that is from March 1 to February 28.
the CCHS, Cycle 1.1. Respondents who scored 0.9
or higher on the Composite International Diagnostic
Interview-Short Form for Major Depression (CIDI-SFMD)
were classified as having probable depression.
Health and Functional Status
CIHI-DAD was used to measure the number of hospital
admissions from March 1, 2005 – February 28, 2006
per 100,000 population aged 15 and older with a most
responsible diagnosis of depression (ICD 10 codes F32,
F33, F412 or F480).
Self-rated health, comorbidity and functioning were
OHIP data were used to measure the proportion of
assessed using four measures from CCHS, Cycle
Ontarians aged 15 and older who saw a physician for
1.1—the percentage of Ontarians with probable
assessment, diagnosis or treatment of a mental health
depression who rated their health as fair or poor, those
condition (OHIP diagnosis codes 300 or 311) during the
who indicated they had no other chronic medical
period March 1, 2005 – February 28, 2006. The fees
conditions, the average number of days in the previous
associated with these visits, based on OHIP fee codes,
two weeks spent out of bed for all or most of the day
were used to calculate the average cost per capita paid
and the average number of days in the previous two
for these core mental health services.
weeks when the person did not have to cut down on
OHIP data were also used to measure the number of
normal activities. The last two measures of functional
electroconvulsive therapy (ECT) users from March 1,
status were derived from the following CCHS questions:
2005 – February 28, 2006 per 100,000 population aged
• During the past 14 days, did you stay in bed at all
15 and older defined as any individual for whom a code
because of illness or injury, including nights spent as a
of G478 or G479 (electroconvulsive therapy cerebral)
patient in a hospital?
was billed.
• Not including bed days, during those 14 days, were
there any days that you cut down on things you
normally do because of illness or injury?
95
Measures of Supply
Women Who Had a Physician Visit for Depression
Administrative data were used to measure supply of
After Giving Birth
medical services. The IPDB was used to identify the
CIHI-DAD was used to identify women who were
number of general practitioners/family physicians and
discharged from hospital (from March 1, 2005 -
the number of psychiatrists available in Ontario per
February 28, 2006) after having given birth. Still births
100,000 population aged 15 and older. The number
were excluded. This cohort was linked, using encrypted
of acute care psychiatric beds available in Ontario was
health card numbers, to the OHIP database to identify
based on estimates available from the Ministry of Health
physician visits for depression (OHIP diagnosis codes
and Long-Term Care’s (MOHLTC) Health Data Branch.
300 or 311) within one year of hospital discharge.
The report was accessed on February 6, 2008 at http://
www.mohltcfim.com/cms/client_webmaster/index.jsp
Physician Visits, Emergency Department Visits
and Readmissions Following Discharge from a
Physician Visits for Depression
Hospital Stay for Depression
Ontarians with probable depression, based on CCHS,
These indicators included all discharges from acute care
Cycle 1.1 were linked (using encrypted health card
hospitals and those psychiatric hospitals included in
numbers) to OHIP data (from the 2000/01 and 2001/02
the CIHI-DAD from March 1, 2005 - February 28, 2006
fiscal years) to identify the number of people with
after an admission for depression (ICD10 codes F32,
probable depression who were seen by a physician for a
F33, F412 or F480).
depression-related visit during the year after the survey
date. OHIP diagnostic codes 300 or 311 were used to
identify ‘depression-related’ visits.
• Discharge records for patients admitted to hospital for
depression were linked to the OHIP database, using
encrypted health card numbers, to determine the
Physician Follow Up for Patients On a New Course
of Antidepressants
The ODB was used to identify patients who started on
a new course of antidepressants and who filled two or
percentage that were seen by a physician for depression
(OHIP diagnostic codes 300 or 311) within 30 days, 12
weeks, six months and one year of discharge. The mean
number of days to the first visit was also calculated.
more prescriptions within 100 days (first prescriptions
• Discharge records for patients admitted to hospital for
filled during the period March 1, 2005 - February 28,
depression were also linked to the NACRS database,
2006). The sample was restricted to adults aged 66
using encrypted health card numbers, to identify the
and older to allow review of data from one year prior
percentage of patients that were seen in an emergency
to confirm that the medication use represented a new
department for any reason within 30 days of discharge
prescription. This cohort was linked, using encrypted
without a resulting hospital admission.
health card numbers, to the OHIP database to identify
• Patients who were discharged from hospital after an
physician visits for depression (OHIP diagnosis codes 300
admission for depression were followed for 30 days
or 311) within 12 weeks of starting medication. Three
from the date of discharge to identify patients who
or more visits during the acute period of treatment are
were readmitted to hospital for depression within 30
recommended.86
days of discharge.
96
5. ANALYSIS
Bivariate analyses were used to estimate differences
by sex. Differences were also estimated by age, neighbourhood income quintile, rural/urban residency, and
Administrative data have the following limitations that
should be considered when interpreting findings from
these data:
• Although coders undergo extensive training and
LHIN and, where the numbers permitted, by sex within
rechecking procedures, variations in interpreting coding
these variables. Indicators based on CCHS data were
and reporting guidelines and in hospital practices may
weighted to represent the demographic makeup of the
create biases in hospital administrative data.
Ontario population during the survey year. For indicators
based on administrative data, indirect age-standardization, using the 2005 Registered Persons Database
(adjusted for the Statistics Canada Census) was applied.
Where numbers were too small, results were either not
reported or were aggregated.
Limitations
The results based on CCHS data should be interpreted
with caution for the following reasons:
• The survey relies on self-reports and voluntary participation of randomly selected participants, and thus the
• Physician claims data have one field for diagnostic
information. Anecdotal information suggests variation
in coding across medical specialties and when patients
present multiple conditions during a single visit. While
cross-province comparisons provide some evidence for
the reliability of physician coding at a gross level,61 there
are likely biases and omissions when using these data to
identify visits for depression.
The following cautions should be kept in mind when
data for the ecological variables (SES, rural/urban) are
interpreted:
data reflect individuals’ interpretation of questions and
• Accuracy of the information depends on the accuracy
how they perceive their own health. Hence, results may
of the data provided to the census or the Ministry of
be an under- or over-estimation of the prevalence of
Health and Long-Term Care (RPDB).
some conditions.
• The CCHS does not survey Aboriginal people living on
• Data definitions may differ (e.g., urban vs. rural) for
various reasons such as changes in population con-
reserves, institutionalized individuals, individuals unable
centration or composition or use of different analytic
to be surveyed in English or French, or persons in the
thresholds (e.g., using quartiles vs. quintiles).
armed forces. While the findings pertain to a large
proportion of Ontarians (those living in households),
they may be biased if the group not surveyed have
significantly different need or utilization rates.
• The CCHS survey was conducted before LHINs were
created and there was inadequate sample size for some
measures for some LHINs. This prevented comparative
analysis of some indicators.
97
TABLE 5.1 | S ummary of critical issues vis-à-vis care for depression
from expert panel survey
Care for depression
continuum point
Issue
Prevention
1. Few gender-specific prevention/public education programs
2. Need programs designed to prevent exposure to likely risk factors and/or
support to at-risk subgroups
should be based on evidence
• Programs
• Populations/factors
to be targeted:
Poverty/low income and depression for women
Parental history of mental illness
Childhood maltreatment
Low SES women with children
Men – recognition and treatment of depression
Workplace stress
Postpartum period for women
Community Services/Supports
3. Few gender specific community services/supports programs
4. Accessibility of such programs (e.g., child care options, non-business hours)
5. [gender-specific] Acceptability of such programs
6. Clinics need to follow current guidelines regarding identifying and either
referral or treatment for depression
7. Vocational support programs need gender-sensitive case finding and
intervention programs
8. Men less likely to access these services. Mental health stigma is higher for men
and male adolescents who have a higher dropout rate in treatment programs
Primary Care
9. Women should be screened for depression (especially postpartum and premenopausal)
10. Need better access (for all) to primary care and especially family physicians
11. Training and capability of primary care providers to recognize and treat mild
to moderate depression
12. Need for primary care to follow guidelines for assessment and treatment of
depression
13. Need for [equitable] interconnection between primary and other types of
care, e.g.,
• Availability
of specialty services that primary care can refer to
• Encouragement
• Access
• Need
of shared care arrangements
to services outside the ones funded by province (e.g., psychologists)
to evaluate if referrals are gender-specific
• Need
to evaluate whether current fee-for-service payments result in perverse
incentives
98
TABLE 5.1 | S ummary of critical issues vis-à-vis care for depression
from expert panel survey
Care for depression
continuum point
Issue
Primary Care
14. More consistent offering and greater availability of evidence-based
psychotherapy as supplement/-alternative to anti-depressants (to counteract
potential overuse of biologicals in affected population which are mostly
women)
15. Need to address stigma—e.g., women viewed as weak and not trying hard
enough to cope with depression. This negatively impacts help-seeking
behaviour and impedes recovery
Acute Hospital Care
16. Bed accessibility
17. Impact of gender on the decision to admit to hospital
18. Need to incorporate the demands of women’s roles as mothers and wives
into the care process.
• Assessment
and care need to explicitly consider the depressed woman’s role as
mother and wife
• Inclusion
in discharge planning for possible need to assistance in caring for
home/family
• Marital
relationships are predictor of recovery and/or relapse. Marital therapy/
counselling is often not offered at discharge
Specialty Hospital Care
Same as #16 - #18
19. Availability of gender-segregated units/wards
20. Relationship of length of stay for mental health [depression] reasons to
gender
21. Need to link to community and primary care services so that inpatient stay is
a short episode in a continuum of care
22. Need for improved community nursing teams to act as case managers and
care coordinators for individual with severe mental illness
Chronic & Rehabilitation Care
Same as #18
23. Cost of non-insured services and medications
24. More attention to work environment regarding readiness to return to work.
Management training and occupational health policies should be targeted.
25. Sheltered accommodation
26. Meaningful employment opportunities
99
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109
funder
Echo: Improving Women’s Health in Ontario
Echo’s mission is to improve the health and wellbeing of Ontario women and to reduce health
inequities. We believe that through knowledge
transfer and gender-based analysis, Echo will improve
the health of women and overall quality of life,
relationships, families and communities in Ontario.
Long-Term Care and is working to ensure Ontario is at
Echo is an agency of the Ministry of Health and
the forefront of improving women’s health.
partners
St. Michael’s Hospital
St. Michael’s Hospital is a vibrant academic teaching
hospital in the heart of downtown Toronto. The
physicians, nurses and staff of St. Michael’s Hospital
provide compassionate care and outstanding medical
education. Critical care, trauma, heart disease,
neurosurgery, diabetes, cancer care and care of the
homeless and vulnerable populations in the inner
city are among the Hospital’s areas of excellence. St.
Keenan Research Centre at the Li Ka Shing
Michael’s Hospital is recognized and respected around
Knowledge Institute Founded in 1892 and
the world for leading-edge research that is bringing
affiliated with the University of Toronto, the Hospital is
new discoveries to patient care through the
downtown Toronto’s designated adult trauma centre.
Institute for Clinical Evaluative Sciences
ICES is an independent, non-profit organization that
uses population-based health information to produce
knowledge on a broad range of health care issues.
110
Our unbiased evidence provides measures of health
resources. ICES knowledge is highly regarded in Canada
system performance, a clearer understanding of the
and abroad, and is widely used by government,
shifting health care needs of Ontarians, and a stimulus
hospitals, planners, and practitioners to make decisions
for discussion of practical solutions to optimize scarce
about care delivery and to develop policy.

Depression Chapter 5

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